critical thinking about evidence

• Choosing Effective Vocabulary
• How to Fill a Page (When You Have Nothing to Say)
• Resources – Books
• Critical Thinking and Reading Skills
• Key Terms and the Inference Continuum
• Bad Inferences – Fallacies and Biases
• Application: Inferences and History
• An Aside: Strong Inferences vs. Ghosts
• Eight Types of Evidence – Strengths and Weaknesses
• Bad Evidence – Fallacies and Poor Appeals
• Value Conflicts and Key Terms
• Tragic Application of Values
• Common Value Systems
• Fallacies and a Few Fun Techniques
• Donna Hicks’s Essential Elements of Dignity
• Fundamental Needs
• Mapping Classroom Culture – Support and Humiliation
• The Dignity Pledge
• Separation and Segregation
• Stripping Away Resources and Protections
• Violence and Intimidation
• Murder and Elimination
• Toxic Mythologies and Deep Narratives
• Scapegoating and Conspiracy Theories
• Caricature and Stereotypes
• Denial and Willful Ignorance
• Conclusion and FAQs

Eight Types of Evidence – Strengths and Weaknesses

Overview: The ability to distinguish sources of evidence allows students to better evaluate and generate information in support of arguments.

Evidence is a huge component of reasoning and argument. Understanding how evidence works and how it might be questioned, probed, or attacked, significantly boosts students’ reasoning ability. The following material offers a vocabulary that can operate as a toolkit for use on any task that requires analysis or generation of evidence.

1. Personal Experience – It happened to you. You know what bronchitis feels like because you had it last year, and it was terrible.

Strengths – Emotionally intense and relevant, collected by your very own senses.

Weaknesses  – The way you interpret your own experiences is very personal and based on your own expectations and biases. Also, your senses have all sorts of flaws, as does your memory. You remember events and moments that are bizarre, intense, or otherwise of interest to you, which is a small sliver of the world around you.

2. Personal Observation – You saw or measured the event. You haven’t had a migraine, but your mom gets them and you have witnessed how painful and awful they can be.

Strengths – Collected by the senses, scientific measurement techniques can carefully and cleverly isolate the information you are seeking.

Weaknesses – The same as Personal Experience, scientific measurements can be corrupted by factors you didn’t anticipate.

3. Testimonial – The experience or observation of someone else; a witness. My friend saw a guy with pink eye yesterday. He said it was pretty gross.

Strengths – They were there, emotional weight of hearing someone’s story or claim. We want to believe one another because lying is so dangerous to our social fabric.

Weaknesses – The person might be mistaken (see weaknesses of Personal Experience), lying, or leaving out important details.

4. Appeal to Authority – The experience or observations of a learned and/or respected person; an expert. My brother is a doctor and treated a guy with a broken arm. He told me that broken bones don’t always hurt as much as you would expect.

Strengths – This person presumably has a lot of access to information, a depth of experience, and a professional reputation on the line.

Weaknesses – Same as Testimonial, the person’s expertise could be based on a depth of experience in field separate from the one we’re dealing with. (See Appeal to Questionable Authority Fallacy).

5. Case Examples – Historical, literary, or other recorded examples. They could be the statements of witnesses or experts, or they could be more general events that we cite to support our claim. War is terrible for soldiers on the ground. You can read all about it in many Civil War diaries.

Strengths – Same data available to everyone, you can carefully seek out and find examples that support your claim (see Confirmation Bias), emotional weight of vivid examples.

Weaknesses – Examples might be isolated and/or unrepresentative of “normal” experience (see Hasty Generalization ).

6. Research Studies   – Large sample of carefully gathered  information scrutinized with statistical tools and peer-reviewed by other experts.

Strengths – Large samples protect against Hasty Generalizations, the same data is available to everyone.

Weaknesses  – There is a long list of potential pitfalls to good research. They include poor design, poor data gathering, and poor data analysis. There are conflicting studies which cite different parts of the same data, and there are weak studies published to push a political agenda.

7. Analogy – Citing a similar circumstance; if it worked in that ugly situation, it will work in this ugly situation. If cigarettes give mice cancer, they probably give humans cancer.

Strengths – Much of life follows general rules; if something works in one place, there’s a pretty good chance it will work in another place.

Weaknesses – Places can be different! You have to look at salient details (a.k.a the details that actually contribute to whatever it is you are looking at). If a flying squirrel can fall from a tall building and survive, I should be able to do the same thing. We are both mammals! (See Bad Analogy Fallacy.)

8. Intuition – Your gut feeling, presumably based on years of experience. It feels true. The inferences that pop into your head first are likely to be based on intuition rather than research studies or other types of evidence. If you hear a bump in the night, the weight of your experience will offer a causal inference, and if that inference isn’t dangerous (“it was just the wind!”), you will likely just go back to sleep.

Strengths  – For most issues, our experience is a good guide to life. We have built a pretty good picture of the world, and we can generally rely on it to stay consistent. Malcolm Gladwell explains the power of quick inferences in his book Blink , and Daniel Kahneman describes it as “fast thinking” in his book Thinking, Fast and Slow .

Weaknesses – Your experience is personal and unique. Other people have had different experiences and will therefore have different gut feelings. There is no way to prove that your intuition is correct. If people trust it, it’s because you have been right many times in the past and will therefore trust you to be right again (see Appeal to Questionable Authority). All of the fallacies and biases that lead us to make weak inferences are relevant here.

Again, this list is adapted from Asking the Right Questions  by Neil Browne and Stuart Keeley, which offers a more in-depth look at each type of evidence. I’ve simplified and adapted their work to serve as an introduction to students new to this approach.

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6.2: Defining Evidence

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• Page ID 67178

• Jim Marteney
• Los Angeles Valley College via ASCCC Open Educational Resources Initiative (OERI)

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What is evidence? According to Reike and Sillars, ”Evidence refers to specific instances, statistics, and testimony, when they support a claim in such a way as to cause the decision maker(s) to grant adherence to that claim.” 1

Evidence is information that answers the question “ How do you know ? ” of a contention you have made. Please take that question very literally. It is often hard to tell the difference at first between telling someone what you know and telling them how you know it. To become an effective arguer in almost any context, you need to be able to ask this question repeatedly and test the answers you hear to determine the strength of the evidence.

Only experts can use phrases like "I think" or "I feel" or "I believe" as they have the qualifications needed that allow you to accept their observations. As for everyone else, we need to use evidence to support our arguments. As a critical thinker, you should rely much more on what a person can prove instead of what a person "feels."

Evidence is a term commonly used to describe the supporting material used when persuading others. Evidence gives an objective support to your arguments, and makes your arguments more than a mere collection of personal opinions or prejudices. No longer are you saying, “ I believe ” or “ I think ” or “ In my opinion .” Now you can support your assertions with evidence. Because you are asking your audience to take a risk when you attempt to persuade them, audiences will demand support for your assertions. Evidence needs to be carefully chosen to serve the needs of the claim and to reach the target audience.

An argument is designed to persuade a resistant audience to accept a claim via the presentation of evidence for the contentions being argued. Evidence establishes the amount of accuracy your arguments have. Evidence is one element of proof (the second is reasoning), that is used as a means of moving your audience toward the threshold necessary for them to grant adherence to your arguments.

Quality argumentation depends in part on the quantity and diversity of evidence. The arguer should expect audiences to not be persuaded by limited evidence or by a lack of variety/scope, evidence drawn from only one source as opposed to diverse sources. On the other hand, too much evidence, particularly when not carefully crafted, may leave the audience overwhelmed and without focus. Evidence in support of the different contentions in the argument needs to make the argument reasonable enough to be accepted by the target audience.

Challenge of Too Much Evidence

I attended a lecture years ago where the guest speaker told us that we have access to more information in one edition of the New York Times than a man in the middle ages had in his entire life time. The challenge is not finding information, the challenge is sorting through information to find quality evidence to use in our arguments and decision-making. In his book, “Data Smog, Surviving the Information Glut”, David Shenk expresses his concern in the first chapter:

“Information has also become a lot cheaper--to produce, to manipulate, to disseminate. All of this has made us information-rich, empowering Americans with the blessings of applied knowledge. It has also, though, unleashed the potential of information-gluttony...How much of the information in our midst is useful, and how much of it gets in the way? ...

As we have accrued more and more of it, information has emerged not only as a currency, but also as a pollutant."

• In 1971 the average American was targeted by at least 560 daily advertising messages. Twenty years later, that number had risen six- fold, to 3,000 messages per day.
• In the office, an average of 60 percent of each person's time is now spent processing documents.
• Paper consumption per capita in the United States tripled from 1940 to 1980 (from 200 to 600 pounds), and tripled again from 1980 to 1990 (to 1,800 pounds).
• In the 1980s, third-class mail (used to send publications) grew thirteen times faster than population growth.
• Two-thirds of business managers surveyed report tension with colleagues, loss of job satisfaction and strained personal relationships as a result of information overload.
• More than 1,000 telemarketing companies employ four million Americans, and generate $650 billion in annual sales.

Let us call this unexpected, unwelcome part of our atmosphere "data smog," an expression for the noxious muck and druck of the information age. Data smog gets in the way; it crowds out quiet moments, and obstructs much-needed contemplation. It spoils conversation, literature, and even entertainment. It thwarts skepticism, rendering us less sophisticated as consumers and citizens. It stresses us out.” 2

We need ways of sorting through this information and the first method is understanding the different types of evidence that we encounter.

Sources of Evidence

The first aspect of evidence we need to explore is the actual source of evidence or where we find evidence. There are two primary sources of evidence; primary and secondary.

Primary Sources

A primary source provides direct or firsthand evidence about an event, object, person, or work of art. Primary sources include historical and legal documents, eyewitness accounts, results of experiments, statistical data, pieces of creative writing, audio and video recordings, speeches, and art objects. Interviews, surveys, fieldwork, and Internet communications via email, blogs, tweets, and newsgroups are also primary sources. In the natural and social sciences, primary sources are often empirical studies—research where an experiment was performed or a direct observation was made. The results of empirical studies are typically found in scholarly articles or papers delivered at conferences. 3

Included in primary sources:

• Original, first-hand accounts of events, activity or time period
• Factual accounts instead of interpretations of accounts or experiments
• Results of an experiment
• Reports of scientific discoveries
• Results of scientifically based polls

Secondary Sources

Secondary sources describe, discuss, interpret, comment upon, analyze, evaluate, summarize, and process primary sources. Secondary source materials can be articles in newspapers or popular magazines, book or movie reviews, or articles found in scholarly journals that discuss or evaluate someone else's original research. 4

Included in secondary sources:

• Analyzation and interpretation of the accounts of primary sources
• Secondhand account of an activity or historical event
• Analyzation and interpretation of scientific or social research results

The key difference between the two sources is how far the author of the evidence is removed from the original event. You want to ask, " Is the author giving you a firsthand account, or a secondhand account? "

Types of Evidence

There are five types of evidence critical thinkers can use to support their arguments: precedent evidence, statistical evidence, testimonial evidence, hearsay evidence, and common knowledge evidence .

Precedent evidence is an act or event which establishes expectations for future conduct. There are two forms of precedent evidence: legal and personal.

Legal precedent is one of the most powerful and most difficult types of evidence to challenge. Courts establish legal precedent. Once a court makes a ruling, that ruling becomes the legal principle upon which other courts base their actions. Legislatures can also establish precedent through the laws they pass and the laws they choose not to pass. Once a principle of law has been established by a legislative body, it is very difficult to reverse.

Personal precedents are the habits and traditions you maintain. They occur as a result of watching the personal actions of others in order to understand the expectations for future behaviors. Younger children in a family watch how the older children are treated in order to see what precedents are being established. Newly employed on a job watch to see what older workers do in terms of breaks and lunchtime in order that their actions may be consistent. The first months of a marriage is essentially a time to establish precedent. Who does the cooking, who takes out the garbage, who cleans, which side of the bed does each person get, are precedents established early in a marriage. Once these precedents are displayed, an expectation of the other’s behavior is established. Such precedent is very difficult to alter.

To use either type of precedent as evidence, the arguer refers to how the past event relates to the current situation. In a legal situation, the argument is that the ruling in the current case should be the same as it was in the past, because they represent similar situations. In a personal situation, if you were allowed to stay out all night by your parents "just once," you can use that "just once" as precedent evidence when asking that your curfew be abolished.

Statistical evidence consists primarily of polls, surveys, and experimental results from the laboratory. This type of evidence is the numerical reporting of specific instances. Statistical evidence provides a means for communicating a large number of specific instances without citing each one. Statistics can be manipulated and misused to make the point of the particular advocate.

Don’t accept statistics just because they are numbers. People often fall into the trap of believing whatever a number says, because numbers seem accurate. Statistics are the product of a process subject to human prejudice, bias, and error. Questions on a survey can be biased, the people surveyed can be selectively chosen, comparisons may be made of non-comparable items, and reports of findings can be slanted. Take a look at all the polls that predict an election outcome. You will find variances and differences in the results.

Statistics have to be interpreted. In a debate over the use of lie detector tests to determine guilt or innocence in court, the pro-side cited a study which found that 98% of lie detector tests were accurate. The pro-side interpreted this to mean that lie detector tests were an effective means for determining guilt or innocence. However, the con-side interpreted the statistic to mean that two out of every 100 defendants in this country would be found guilty and punished for a crime they did not commit.

The great baseball announcer Vin Scully once described the misuse of statistics by a journalist by saying that “ He uses statistics like a drunk uses a lamppost, not for illumination but for support

Statistics are often no more reliable than other forms of evidence, although people often think they are. Advocates need to carefully analyze how they use statistics when attempting to persuade others. Likewise, the audience needs to question statistics that don't make sense to them.

Testimonial evidence is used for the purpose of assigning motives, assessing responsibilities, and verifying actions for past, present and future events. Testimony is an opinion of reality as stated by another person. There are three forms of testimonial evidence: eyewitness, expert-witness, and historiography.

Eyewitness testimony is a personal declaration as to the accuracy of an event. That is, the person actually saw an event take place and is willing to bear witness to that event. Studies have confirmed that eyewitness testimony, even with all of its problems, is a powerful form of evidence. There seems to be almost something "magical" about a person swearing to "tell the whole truth and nothing but the truth."

Expert-witness evidence calls upon someone qualified to make a personal declaration about the nature of the fact in question. Courts of law make use of experts in such fields as forensics, ballistics, and psychology. The critical thinker uses the credibility of another person to support an argument through statements about the facts or opinions of the situation.

What or who qualifies as an expert witness? Does being a former military officer make them an expert in military tactics? Often an advocate will merely pick someone who they know the audience will accept. But as an audience we should demand that advocates justify the expertise of their witness. As we acquire more knowledge, our standards of what constitutes an expert should rise. We need to make a distinction between sources that are simply credible like well-known athletes and entertainers that urge you to buy a particular product, and those who really have the qualities that allow them to make a judgment about a subject in the argumentative environment.

Although expert witness testimony is an important source of evidence, such experts can disagree. In a recent House Energy and Commerce subcommittee, two experts gave opposite testimony, on the same day, on a bill calling for a label on all aspirin containers warning of the drug's often fatal link to Reye's Syndrome. The head of the American Academy of Pediatrics gave testimony supporting the link, but Dr. Joseph White, President of The Aspirin Foundation of America, said there was insufficient evidence linking aspirin to Reye’s syndrome.

Historiography is the third form of testimonial evidence. In their book, ARGUMENTATION AND ADVOCACY, Windes and Hastings write, "Historiographers are concerned in large part with the discovery, use, and verification of evidence. The historian traces influences, assigns motives, evaluates roles, allocates responsibilities, and juxtaposes events in an attempt to reconstruct the past. That reconstruction is no wiser, no more accurate or dependable than the dependability of the evidence the historian uses for his reconstruction." 5

Keep in mind that there are many different ways of determining how history happens. Remember, historians may disagree over why almost any event happened. In the search for how things happen, we get ideas about how to understand our present world's events and what to do about them, if anything.

Primary sources are essential to the study of history. They are the basis for what we know about the distant past and the recent past. Historians must depend on other evidence from the era to determine who said what, who did what, and why.

How successful is the historian in recreating “objective reality?" As noted historian Arthur Schlesinger, Jr. says,

“The sad fact is that, in many cases, the basic evidence for the historian’s reconstruction of the really hard cases does not exist, and the evidence that does exist is often incomplete, misleading, or erroneous. Yet, it is the character of the evidence which establishes the framework within which he writes. He cannot imagine scenes for which he has no citation, invent dialogue for which he has no text, assume relationships for which he has no warrant.”

Historical reconstruction must be done by a qualified individual to be classified as historical evidence. Critical thinkers will find it useful to consider the following three criteria for evaluating historical evidence.

Around 1,000 books are published internationally every day and the total of all printed knowledge doubles every 5 years.

More information is estimated to have been produced in the last 30 years than in the previous 5,000.

----The Reuters Guide to Good Information Strategy 2000

Was the author an eyewitness to what is being described, or is the author considered an authority on the subject? Eyewitness accounts can be the most objective and valuable but they may also be tainted with bias. If the author professes to be an authority, he/she should present his/her qualifications.

Does the author have a hidden agenda? The author may purposely or unwittingly tell only part of the story. The excerpt may seem to be a straight-forward account of the situation, yet the author has selected certain facts, details, and language, which advance professional, personal or political goals or beliefs. They may be factual, but the hidden agenda of these books was to make money for the author, or get even with those in the administration they didn't like.

Does the author have a bias? The author's views may be based on personal prejudice rather than a reasoned conclusion based on facts. Critical thinkers need to notice when the author uses exaggerated language, fails to acknowledge, or dismisses his or her opponents' arguments. Historians may have biases based on their political allegiance. Conservative historians would view events differently than a liberal historian. It is important to know the political persuasion of the historian in order to determine the extent of bias he or she might have on the specific topic they are writing about.

Sometimes we think we might know our history, but Historian Daniel Boorstin puts a perspective on the ultimate validity and accuracy of historical testimony when he writes, "Education is learning what you didn't even know you didn't know." Modern techniques of preserving data should make the task of recreating the past easier and adding to our education.

Hearsay evidence (also called rumor or gossip evidence) can be defined as an assertion or set of assertions widely repeated from person to person, though its accuracy is unconfirmed by firsthand observation. "Rumor is not always wrong , " wrote Tacitus, the Roman historian. A given rumor may be spontaneous or premeditated in origin. It may consist of opinion represented as fact, a nugget of accuracy garbled or misrepresented to the point of falsehood, exaggerations, or outright, intentional lies. Yet, hearsay may well be the "best available evidence" in certain situations where the original source of the information cannot be produced.

Rumor, gossip or hearsay evidence carries proportionately higher risks of distortion and error than other types of evidence. However, outside the courtroom, it can be as effective as any other form of evidence in proving your point. Large companies often rely on this type of evidence, because they lack the capability to deliver other types of evidence.

A recent rumor was started that actor Morgan Freeman had died. A page on “Facebook” was created and soon gained more that 60,000 followers, after it was announced that the actor had passed away. Many left their condolences and messages of tribute. Only one problem, Morgan Freeman was very much alive, actually that is not so much a problem, especially to Morgan Freeman. The Internet is a very effective tool when it comes to spreading rumors.

Common knowledge evidence is also a way to support one’s arguments. This type of evidence is most useful in providing support for arguments which lack any real controversy. Many claims are supported by evidence that comes as no particular surprise to anyone.

Basing an argument on common knowledge is the easiest method of securing belief in an idea, because an audience will accept it without further challenge. As Communication Professors Patterson and Zarefsky explain:

“Many argumentative claims we make are based on knowledge generally accepted by most people as true. For example, if you claimed that millions of Americans watch television each day, the claim would probably be accepted without evidence. Nor would you need to cite opinions or survey results to get most people to accept the statement that millions of people smoke cigarettes." 6 (Patterson, 1983)

Credibility of Evidence or How Good Is It?

In order to tell us how you know something, you need to tell us where the information came from. If you personally observed the case you are telling us about, you need to tell us that you observed it, and when and where. If you read about it, you need to tell us where you read about it. If you are accepting the testimony of an expert, you need to tell us who the expert is and why she is an expert in this field. The specific identity, name or position and qualifications of your sources are part of the answer to the question “How do you know?” You need to give your audience that information.

Keep in mind that it is the person, the individual human being, who wrote an article or expressed an idea who brings authority to the claim. Sometimes that authority may be reinforced by the publication in which the claim appeared, sometimes not. But when you quote or paraphrase a source you are quoting or paraphrasing the author, not the magazine or journal. The credibility of the evidence you use can be enhanced by:

Specific Reference to Source : Does the advocate indicate the particular individual or group making the statements used for evidence? Does the advocate tell you enough about the source that you could easily find it yourself?

Qualifications of the Source: Does the advocate give you reason to believe that the source is competent and well-informed in the area in question?

Bias of the Source : Even if an expert, is the source likely to be biased on the topic? Could we easily predict the source’s position merely from knowledge of his job, her political party, or organizations he or she works for?

Factual Support: Does the source offer factual support for the position taken or simply state personal opinions as fact?

Evaluating Internet Sources of Evidence

We currently obtain a significant amount of the evidence we use in an argument from the Internet. Some people are still under the influence that if they read it on the Internet, it must be accurate. But we all know that some Internet sources are better than others. We need to be able to evaluate websites to obtain the best information possible. Here are two approaches to evaluating websites

Who, What, When, Where, and Why

This first test is based on the traditional 5 “W’s.” These questions, like critical thinking, go back to Greek and Roman times. The notable Roman, Cicero, who was in office in 63 BC, is credited with asking these questions

Journalists are taught to answer these five questions when writing an article for publication. To provide an accurate interpretation of events to their viewers or readers, they ask these five questions and we can ask the same questions to begin discovering the level of quality of an online source.

Who wrote the post? What are their qualifications?

What is actually being said in the website. How accurate is the content?

When was the website’s latest post?

Where is the source of the post? Does the URL suggest it is from an academic source or an individual?

Why is the website published? Is the website there to inform or entertain?

There is a second method of evaluating websites that is more popular and includes a more in depth analysis. This method is known as the CRAAP test.

The C.R.A.A.P. Test

C.R.A.A.P. is an acronym standing for Currency, Relevance, Authority, Accuracy, and Purpose. Developed by the Meriam Library at the California State University at Chico, each of these five areas is used to evaluate websites.

Currency How recent is this website. If you are conducting research on some historical subject a web site that has no recent additions could be useful. If, however you are researching some current news story, or technology, or scientific topic, you will want a site that has been recently updated.

Questions to Ask:

• When was the content of the website published or posted?
• Has the information been revised or updated recently?
• Have more recent articles on your subject been published?
• Does your topic require the most current information possible, or will older posts and sources be acceptable?
• Are the web links included in the website functional?
• Relevance This test of a website asks you how important is the information to the specific topic you are researching. You will want to determine if you are the intended audience and if the information provided fits your research needs.
• Does the content relate to your research topic or the question you are answering?
• Who is the intended audience?
• Is the information at an appropriate level for the purpose of your work? In other words, is it college level or targeted to a younger or less educated audience?
• Have you compared this site to a variety of other resources?
• Would you be comfortable citing this source in your research project?

Authority Here we determine if the source of the website has the credentials to write on the subject which makes you feel comfortable in using the content. If you are looking for an accurate interpretation of news events, you will want to know if the author of the website is a qualified journalist or a random individual reposting content.

• Who is the author/ publisher/ source/ sponsor of the website?
• What are the author’s credentials or organizational affiliations?
• Does the author have the qualifications to write on this particular topic?
• Can you find information about the author from reference sources or the Internet?
• Is the author quoted or referred to on other respected sources or websites?
• Is there contact information, such as a publisher or email address?
• Does the URL reveal anything about the author or source?

Accuracy In this test we attempt to determine the reliability and accuracy of the content of the website. You need to determine if you can trust the information presented in the website or is it just slanted, personal beliefs.

• Where does the information in the website come from?
• Is the information supported by Evidence, or is it just opinion?
• Has the information presented been reviewed by qualified sources?
• Can you verify any of the content in another source or personal knowledge?
• Are there statements in the website you know to be false?
• Does the language or tone used in the website appear unbiased or free of emotion or loaded language?
• Are there spelling, grammar or typographical errors in the content of the website?

Purpose Finally we examine the purpose of the website. We need to determine if the website was created to inform, entertain or even sell a product or service. If we want accurate, high quality evidence, we would want to avoid a site that is trying to sell us something. Although a company selling solar power may have some factual information about solar energy on their site, the site is geared to sell you their product. The information they provide is not there to educate you with all aspects of solar power.

• What is the purpose of the content of this website? Is the purpose to inform, teach, sell, entertain or persuade?
• Do the authors/sponsors of the website make their intentions or purpose clear?
• Is the content in the website considered facts, opinion, or even propaganda?
• Does the point of view appear objective and impartial?
• Does the author omit important facts or data that might disprove the claim being made in the post?
• Are alternative points of view presented?
• Does the content of the website contain political, ideological, cultural, religious, institutional or personal biases?

Questions used here are inspired from questions from the Meriam Library at California State University Chico, the University of Maryland University College Library and Creighton University Library

• Rieke, Richard D. and Malcolm Sillars. Argumentation and Critical Decision Making. (New York: HaperCollins Rhetoric and Society Series, 1993)
• Shenk, David. Data Smog, Surviving the Information Glut. 1. San Fransisco: HarperEdge, 1997
• Ithica College, "Primary and Secondary Sources," libguides.ithaca.edu/research101/primary (accessed October 31, 2019)
• ARGUMENTATION AND ADVOCACY. By Russel R. Windes and Arthur Hastings. New York: Random House, 1965
• Patterson, J. W. and David Zarefsky. Contemporary Debate. Boston: Houghton Mifflin, 1983

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Critical Thinking

Developing the right mindset and skills.

By the Mind Tools Content Team

We make hundreds of decisions every day and, whether we realize it or not, we're all critical thinkers.

We use critical thinking each time we weigh up our options, prioritize our responsibilities, or think about the likely effects of our actions. It's a crucial skill that helps us to cut out misinformation and make wise decisions. The trouble is, we're not always very good at it!

In this article, we'll explore the key skills that you need to develop your critical thinking skills, and how to adopt a critical thinking mindset, so that you can make well-informed decisions.

What Is Critical Thinking?

Critical thinking is the discipline of rigorously and skillfully using information, experience, observation, and reasoning to guide your decisions, actions, and beliefs. You'll need to actively question every step of your thinking process to do it well.

Collecting, analyzing and evaluating information is an important skill in life, and a highly valued asset in the workplace. People who score highly in critical thinking assessments are also rated by their managers as having good problem-solving skills, creativity, strong decision-making skills, and good overall performance. [1]

Key Critical Thinking Skills

Critical thinkers possess a set of key characteristics which help them to question information and their own thinking. Focus on the following areas to develop your critical thinking skills:

Being willing and able to explore alternative approaches and experimental ideas is crucial. Can you think through "what if" scenarios, create plausible options, and test out your theories? If not, you'll tend to write off ideas and options too soon, so you may miss the best answer to your situation.

To nurture your curiosity, stay up to date with facts and trends. You'll overlook important information if you allow yourself to become "blinkered," so always be open to new information.

But don't stop there! Look for opposing views or evidence to challenge your information, and seek clarification when things are unclear. This will help you to reassess your beliefs and make a well-informed decision later. Read our article, Opening Closed Minds , for more ways to stay receptive.

Logical Thinking

You must be skilled at reasoning and extending logic to come up with plausible options or outcomes.

It's also important to emphasize logic over emotion. Emotion can be motivating but it can also lead you to take hasty and unwise action, so control your emotions and be cautious in your judgments. Know when a conclusion is "fact" and when it is not. "Could-be-true" conclusions are based on assumptions and must be tested further. Read our article, Logical Fallacies , for help with this.

Use creative problem solving to balance cold logic. By thinking outside of the box you can identify new possible outcomes by using pieces of information that you already have.

Self-Awareness

Many of the decisions we make in life are subtly informed by our values and beliefs. These influences are called cognitive biases and it can be difficult to identify them in ourselves because they're often subconscious.

Practicing self-awareness will allow you to reflect on the beliefs you have and the choices you make. You'll then be better equipped to challenge your own thinking and make improved, unbiased decisions.

One particularly useful tool for critical thinking is the Ladder of Inference . It allows you to test and validate your thinking process, rather than jumping to poorly supported conclusions.

Developing a Critical Thinking Mindset

Combine the above skills with the right mindset so that you can make better decisions and adopt more effective courses of action. You can develop your critical thinking mindset by following this process:

Gather Information

First, collect data, opinions and facts on the issue that you need to solve. Draw on what you already know, and turn to new sources of information to help inform your understanding. Consider what gaps there are in your knowledge and seek to fill them. And look for information that challenges your assumptions and beliefs.

Be sure to verify the authority and authenticity of your sources. Not everything you read is true! Use this checklist to ensure that your information is valid:

• Are your information sources trustworthy ? (For example, well-respected authors, trusted colleagues or peers, recognized industry publications, websites, blogs, etc.)
• Is the information you have gathered up to date ?
• Has the information received any direct criticism ?
• Does the information have any errors or inaccuracies ?
• Is there any evidence to support or corroborate the information you have gathered?
• Is the information you have gathered subjective or biased in any way? (For example, is it based on opinion, rather than fact? Is any of the information you have gathered designed to promote a particular service or organization?)

If any information appears to be irrelevant or invalid, don't include it in your decision making. But don't omit information just because you disagree with it, or your final decision will be flawed and bias.

Now observe the information you have gathered, and interpret it. What are the key findings and main takeaways? What does the evidence point to? Start to build one or two possible arguments based on what you have found.

You'll need to look for the details within the mass of information, so use your powers of observation to identify any patterns or similarities. You can then analyze and extend these trends to make sensible predictions about the future.

To help you to sift through the multiple ideas and theories, it can be useful to group and order items according to their characteristics. From here, you can compare and contrast the different items. And once you've determined how similar or different things are from one another, Paired Comparison Analysis can help you to analyze them.

The final step involves challenging the information and rationalizing its arguments.

Apply the laws of reason (induction, deduction, analogy) to judge an argument and determine its merits. To do this, it's essential that you can determine the significance and validity of an argument to put it in the correct perspective. Take a look at our article, Rational Thinking , for more information about how to do this.

Once you have considered all of the arguments and options rationally, you can finally make an informed decision.

Afterward, take time to reflect on what you have learned and what you found challenging. Step back from the detail of your decision or problem, and look at the bigger picture. Record what you've learned from your observations and experience.

Critical thinking involves rigorously and skilfully using information, experience, observation, and reasoning to guide your decisions, actions and beliefs. It's a useful skill in the workplace and in life.

You'll need to be curious and creative to explore alternative possibilities, but rational to apply logic, and self-aware to identify when your beliefs could affect your decisions or actions.

You can demonstrate a high level of critical thinking by validating your information, analyzing its meaning, and finally evaluating the argument.

Critical Thinking Infographic

See Critical Thinking represented in our infographic: An Elementary Guide to Critical Thinking .

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Critical Thinking

Critical thinking is a widely accepted educational goal. Its definition is contested, but the competing definitions can be understood as differing conceptions of the same basic concept: careful thinking directed to a goal. Conceptions differ with respect to the scope of such thinking, the type of goal, the criteria and norms for thinking carefully, and the thinking components on which they focus. Its adoption as an educational goal has been recommended on the basis of respect for students’ autonomy and preparing students for success in life and for democratic citizenship. “Critical thinkers” have the dispositions and abilities that lead them to think critically when appropriate. The abilities can be identified directly; the dispositions indirectly, by considering what factors contribute to or impede exercise of the abilities. Standardized tests have been developed to assess the degree to which a person possesses such dispositions and abilities. Educational intervention has been shown experimentally to improve them, particularly when it includes dialogue, anchored instruction, and mentoring. Controversies have arisen over the generalizability of critical thinking across domains, over alleged bias in critical thinking theories and instruction, and over the relationship of critical thinking to other types of thinking.

2.1 Dewey’s Three Main Examples

2.2 dewey’s other examples, 2.3 further examples, 2.4 non-examples, 3. the definition of critical thinking, 4. its value, 5. the process of thinking critically, 6. components of the process, 7. contributory dispositions and abilities, 8.1 initiating dispositions, 8.2 internal dispositions, 9. critical thinking abilities, 10. required knowledge, 11. educational methods, 12.1 the generalizability of critical thinking, 12.2 bias in critical thinking theory and pedagogy, 12.3 relationship of critical thinking to other types of thinking, other internet resources, related entries.

Use of the term ‘critical thinking’ to describe an educational goal goes back to the American philosopher John Dewey (1910), who more commonly called it ‘reflective thinking’. He defined it as

active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it, and the further conclusions to which it tends. (Dewey 1910: 6; 1933: 9)

and identified a habit of such consideration with a scientific attitude of mind. His lengthy quotations of Francis Bacon, John Locke, and John Stuart Mill indicate that he was not the first person to propose development of a scientific attitude of mind as an educational goal.

In the 1930s, many of the schools that participated in the Eight-Year Study of the Progressive Education Association (Aikin 1942) adopted critical thinking as an educational goal, for whose achievement the study’s Evaluation Staff developed tests (Smith, Tyler, & Evaluation Staff 1942). Glaser (1941) showed experimentally that it was possible to improve the critical thinking of high school students. Bloom’s influential taxonomy of cognitive educational objectives (Bloom et al. 1956) incorporated critical thinking abilities. Ennis (1962) proposed 12 aspects of critical thinking as a basis for research on the teaching and evaluation of critical thinking ability.

Since 1980, an annual international conference in California on critical thinking and educational reform has attracted tens of thousands of educators from all levels of education and from many parts of the world. Also since 1980, the state university system in California has required all undergraduate students to take a critical thinking course. Since 1983, the Association for Informal Logic and Critical Thinking has sponsored sessions in conjunction with the divisional meetings of the American Philosophical Association (APA). In 1987, the APA’s Committee on Pre-College Philosophy commissioned a consensus statement on critical thinking for purposes of educational assessment and instruction (Facione 1990a). Researchers have developed standardized tests of critical thinking abilities and dispositions; for details, see the Supplement on Assessment . Educational jurisdictions around the world now include critical thinking in guidelines for curriculum and assessment.

For details on this history, see the Supplement on History .

2. Examples and Non-Examples

Before considering the definition of critical thinking, it will be helpful to have in mind some examples of critical thinking, as well as some examples of kinds of thinking that would apparently not count as critical thinking.

Dewey (1910: 68–71; 1933: 91–94) takes as paradigms of reflective thinking three class papers of students in which they describe their thinking. The examples range from the everyday to the scientific.

Transit : “The other day, when I was down town on 16th Street, a clock caught my eye. I saw that the hands pointed to 12:20. This suggested that I had an engagement at 124th Street, at one o’clock. I reasoned that as it had taken me an hour to come down on a surface car, I should probably be twenty minutes late if I returned the same way. I might save twenty minutes by a subway express. But was there a station near? If not, I might lose more than twenty minutes in looking for one. Then I thought of the elevated, and I saw there was such a line within two blocks. But where was the station? If it were several blocks above or below the street I was on, I should lose time instead of gaining it. My mind went back to the subway express as quicker than the elevated; furthermore, I remembered that it went nearer than the elevated to the part of 124th Street I wished to reach, so that time would be saved at the end of the journey. I concluded in favor of the subway, and reached my destination by one o’clock.” (Dewey 1910: 68–69; 1933: 91–92)

Ferryboat : “Projecting nearly horizontally from the upper deck of the ferryboat on which I daily cross the river is a long white pole, having a gilded ball at its tip. It suggested a flagpole when I first saw it; its color, shape, and gilded ball agreed with this idea, and these reasons seemed to justify me in this belief. But soon difficulties presented themselves. The pole was nearly horizontal, an unusual position for a flagpole; in the next place, there was no pulley, ring, or cord by which to attach a flag; finally, there were elsewhere on the boat two vertical staffs from which flags were occasionally flown. It seemed probable that the pole was not there for flag-flying.

“I then tried to imagine all possible purposes of the pole, and to consider for which of these it was best suited: (a) Possibly it was an ornament. But as all the ferryboats and even the tugboats carried poles, this hypothesis was rejected. (b) Possibly it was the terminal of a wireless telegraph. But the same considerations made this improbable. Besides, the more natural place for such a terminal would be the highest part of the boat, on top of the pilot house. (c) Its purpose might be to point out the direction in which the boat is moving.

“In support of this conclusion, I discovered that the pole was lower than the pilot house, so that the steersman could easily see it. Moreover, the tip was enough higher than the base, so that, from the pilot’s position, it must appear to project far out in front of the boat. Moreover, the pilot being near the front of the boat, he would need some such guide as to its direction. Tugboats would also need poles for such a purpose. This hypothesis was so much more probable than the others that I accepted it. I formed the conclusion that the pole was set up for the purpose of showing the pilot the direction in which the boat pointed, to enable him to steer correctly.” (Dewey 1910: 69–70; 1933: 92–93)

Bubbles : “In washing tumblers in hot soapsuds and placing them mouth downward on a plate, bubbles appeared on the outside of the mouth of the tumblers and then went inside. Why? The presence of bubbles suggests air, which I note must come from inside the tumbler. I see that the soapy water on the plate prevents escape of the air save as it may be caught in bubbles. But why should air leave the tumbler? There was no substance entering to force it out. It must have expanded. It expands by increase of heat, or by decrease of pressure, or both. Could the air have become heated after the tumbler was taken from the hot suds? Clearly not the air that was already entangled in the water. If heated air was the cause, cold air must have entered in transferring the tumblers from the suds to the plate. I test to see if this supposition is true by taking several more tumblers out. Some I shake so as to make sure of entrapping cold air in them. Some I take out holding mouth downward in order to prevent cold air from entering. Bubbles appear on the outside of every one of the former and on none of the latter. I must be right in my inference. Air from the outside must have been expanded by the heat of the tumbler, which explains the appearance of the bubbles on the outside. But why do they then go inside? Cold contracts. The tumbler cooled and also the air inside it. Tension was removed, and hence bubbles appeared inside. To be sure of this, I test by placing a cup of ice on the tumbler while the bubbles are still forming outside. They soon reverse” (Dewey 1910: 70–71; 1933: 93–94).

Dewey (1910, 1933) sprinkles his book with other examples of critical thinking. We will refer to the following.

Weather : A man on a walk notices that it has suddenly become cool, thinks that it is probably going to rain, looks up and sees a dark cloud obscuring the sun, and quickens his steps (1910: 6–10; 1933: 9–13).

Disorder : A man finds his rooms on his return to them in disorder with his belongings thrown about, thinks at first of burglary as an explanation, then thinks of mischievous children as being an alternative explanation, then looks to see whether valuables are missing, and discovers that they are (1910: 82–83; 1933: 166–168).

Typhoid : A physician diagnosing a patient whose conspicuous symptoms suggest typhoid avoids drawing a conclusion until more data are gathered by questioning the patient and by making tests (1910: 85–86; 1933: 170).

Blur : A moving blur catches our eye in the distance, we ask ourselves whether it is a cloud of whirling dust or a tree moving its branches or a man signaling to us, we think of other traits that should be found on each of those possibilities, and we look and see if those traits are found (1910: 102, 108; 1933: 121, 133).

Suction pump : In thinking about the suction pump, the scientist first notes that it will draw water only to a maximum height of 33 feet at sea level and to a lesser maximum height at higher elevations, selects for attention the differing atmospheric pressure at these elevations, sets up experiments in which the air is removed from a vessel containing water (when suction no longer works) and in which the weight of air at various levels is calculated, compares the results of reasoning about the height to which a given weight of air will allow a suction pump to raise water with the observed maximum height at different elevations, and finally assimilates the suction pump to such apparently different phenomena as the siphon and the rising of a balloon (1910: 150–153; 1933: 195–198).

Diamond : A passenger in a car driving in a diamond lane reserved for vehicles with at least one passenger notices that the diamond marks on the pavement are far apart in some places and close together in others. Why? The driver suggests that the reason may be that the diamond marks are not needed where there is a solid double line separating the diamond lane from the adjoining lane, but are needed when there is a dotted single line permitting crossing into the diamond lane. Further observation confirms that the diamonds are close together when a dotted line separates the diamond lane from its neighbour, but otherwise far apart.

Rash : A woman suddenly develops a very itchy red rash on her throat and upper chest. She recently noticed a mark on the back of her right hand, but was not sure whether the mark was a rash or a scrape. She lies down in bed and thinks about what might be causing the rash and what to do about it. About two weeks before, she began taking blood pressure medication that contained a sulfa drug, and the pharmacist had warned her, in view of a previous allergic reaction to a medication containing a sulfa drug, to be on the alert for an allergic reaction; however, she had been taking the medication for two weeks with no such effect. The day before, she began using a new cream on her neck and upper chest; against the new cream as the cause was mark on the back of her hand, which had not been exposed to the cream. She began taking probiotics about a month before. She also recently started new eye drops, but she supposed that manufacturers of eye drops would be careful not to include allergy-causing components in the medication. The rash might be a heat rash, since she recently was sweating profusely from her upper body. Since she is about to go away on a short vacation, where she would not have access to her usual physician, she decides to keep taking the probiotics and using the new eye drops but to discontinue the blood pressure medication and to switch back to the old cream for her neck and upper chest. She forms a plan to consult her regular physician on her return about the blood pressure medication.

Candidate : Although Dewey included no examples of thinking directed at appraising the arguments of others, such thinking has come to be considered a kind of critical thinking. We find an example of such thinking in the performance task on the Collegiate Learning Assessment (CLA+), which its sponsoring organization describes as

a performance-based assessment that provides a measure of an institution’s contribution to the development of critical-thinking and written communication skills of its students. (Council for Aid to Education 2017)

A sample task posted on its website requires the test-taker to write a report for public distribution evaluating a fictional candidate’s policy proposals and their supporting arguments, using supplied background documents, with a recommendation on whether to endorse the candidate.

Immediate acceptance of an idea that suggests itself as a solution to a problem (e.g., a possible explanation of an event or phenomenon, an action that seems likely to produce a desired result) is “uncritical thinking, the minimum of reflection” (Dewey 1910: 13). On-going suspension of judgment in the light of doubt about a possible solution is not critical thinking (Dewey 1910: 108). Critique driven by a dogmatically held political or religious ideology is not critical thinking; thus Paulo Freire (1968 [1970]) is using the term (e.g., at 1970: 71, 81, 100, 146) in a more politically freighted sense that includes not only reflection but also revolutionary action against oppression. Derivation of a conclusion from given data using an algorithm is not critical thinking.

What is critical thinking? There are many definitions. Ennis (2016) lists 14 philosophically oriented scholarly definitions and three dictionary definitions. Following Rawls (1971), who distinguished his conception of justice from a utilitarian conception but regarded them as rival conceptions of the same concept, Ennis maintains that the 17 definitions are different conceptions of the same concept. Rawls articulated the shared concept of justice as

a characteristic set of principles for assigning basic rights and duties and for determining… the proper distribution of the benefits and burdens of social cooperation. (Rawls 1971: 5)

Bailin et al. (1999b) claim that, if one considers what sorts of thinking an educator would take not to be critical thinking and what sorts to be critical thinking, one can conclude that educators typically understand critical thinking to have at least three features.

• It is done for the purpose of making up one’s mind about what to believe or do.
• The person engaging in the thinking is trying to fulfill standards of adequacy and accuracy appropriate to the thinking.
• The thinking fulfills the relevant standards to some threshold level.

One could sum up the core concept that involves these three features by saying that critical thinking is careful goal-directed thinking. This core concept seems to apply to all the examples of critical thinking described in the previous section. As for the non-examples, their exclusion depends on construing careful thinking as excluding jumping immediately to conclusions, suspending judgment no matter how strong the evidence, reasoning from an unquestioned ideological or religious perspective, and routinely using an algorithm to answer a question.

If the core of critical thinking is careful goal-directed thinking, conceptions of it can vary according to its presumed scope, its presumed goal, one’s criteria and threshold for being careful, and the thinking component on which one focuses. As to its scope, some conceptions (e.g., Dewey 1910, 1933) restrict it to constructive thinking on the basis of one’s own observations and experiments, others (e.g., Ennis 1962; Fisher & Scriven 1997; Johnson 1992) to appraisal of the products of such thinking. Ennis (1991) and Bailin et al. (1999b) take it to cover both construction and appraisal. As to its goal, some conceptions restrict it to forming a judgment (Dewey 1910, 1933; Lipman 1987; Facione 1990a). Others allow for actions as well as beliefs as the end point of a process of critical thinking (Ennis 1991; Bailin et al. 1999b). As to the criteria and threshold for being careful, definitions vary in the term used to indicate that critical thinking satisfies certain norms: “intellectually disciplined” (Scriven & Paul 1987), “reasonable” (Ennis 1991), “skillful” (Lipman 1987), “skilled” (Fisher & Scriven 1997), “careful” (Bailin & Battersby 2009). Some definitions specify these norms, referring variously to “consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends” (Dewey 1910, 1933); “the methods of logical inquiry and reasoning” (Glaser 1941); “conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication” (Scriven & Paul 1987); the requirement that “it is sensitive to context, relies on criteria, and is self-correcting” (Lipman 1987); “evidential, conceptual, methodological, criteriological, or contextual considerations” (Facione 1990a); and “plus-minus considerations of the product in terms of appropriate standards (or criteria)” (Johnson 1992). Stanovich and Stanovich (2010) propose to ground the concept of critical thinking in the concept of rationality, which they understand as combining epistemic rationality (fitting one’s beliefs to the world) and instrumental rationality (optimizing goal fulfillment); a critical thinker, in their view, is someone with “a propensity to override suboptimal responses from the autonomous mind” (2010: 227). These variant specifications of norms for critical thinking are not necessarily incompatible with one another, and in any case presuppose the core notion of thinking carefully. As to the thinking component singled out, some definitions focus on suspension of judgment during the thinking (Dewey 1910; McPeck 1981), others on inquiry while judgment is suspended (Bailin & Battersby 2009, 2021), others on the resulting judgment (Facione 1990a), and still others on responsiveness to reasons (Siegel 1988). Kuhn (2019) takes critical thinking to be more a dialogic practice of advancing and responding to arguments than an individual ability.

In educational contexts, a definition of critical thinking is a “programmatic definition” (Scheffler 1960: 19). It expresses a practical program for achieving an educational goal. For this purpose, a one-sentence formulaic definition is much less useful than articulation of a critical thinking process, with criteria and standards for the kinds of thinking that the process may involve. The real educational goal is recognition, adoption and implementation by students of those criteria and standards. That adoption and implementation in turn consists in acquiring the knowledge, abilities and dispositions of a critical thinker.

Conceptions of critical thinking generally do not include moral integrity as part of the concept. Dewey, for example, took critical thinking to be the ultimate intellectual goal of education, but distinguished it from the development of social cooperation among school children, which he took to be the central moral goal. Ennis (1996, 2011) added to his previous list of critical thinking dispositions a group of dispositions to care about the dignity and worth of every person, which he described as a “correlative” (1996) disposition without which critical thinking would be less valuable and perhaps harmful. An educational program that aimed at developing critical thinking but not the correlative disposition to care about the dignity and worth of every person, he asserted, “would be deficient and perhaps dangerous” (Ennis 1996: 172).

Dewey thought that education for reflective thinking would be of value to both the individual and society; recognition in educational practice of the kinship to the scientific attitude of children’s native curiosity, fertile imagination and love of experimental inquiry “would make for individual happiness and the reduction of social waste” (Dewey 1910: iii). Schools participating in the Eight-Year Study took development of the habit of reflective thinking and skill in solving problems as a means to leading young people to understand, appreciate and live the democratic way of life characteristic of the United States (Aikin 1942: 17–18, 81). Harvey Siegel (1988: 55–61) has offered four considerations in support of adopting critical thinking as an educational ideal. (1) Respect for persons requires that schools and teachers honour students’ demands for reasons and explanations, deal with students honestly, and recognize the need to confront students’ independent judgment; these requirements concern the manner in which teachers treat students. (2) Education has the task of preparing children to be successful adults, a task that requires development of their self-sufficiency. (3) Education should initiate children into the rational traditions in such fields as history, science and mathematics. (4) Education should prepare children to become democratic citizens, which requires reasoned procedures and critical talents and attitudes. To supplement these considerations, Siegel (1988: 62–90) responds to two objections: the ideology objection that adoption of any educational ideal requires a prior ideological commitment and the indoctrination objection that cultivation of critical thinking cannot escape being a form of indoctrination.

Despite the diversity of our 11 examples, one can recognize a common pattern. Dewey analyzed it as consisting of five phases:

• suggestions , in which the mind leaps forward to a possible solution;
• an intellectualization of the difficulty or perplexity into a problem to be solved, a question for which the answer must be sought;
• the use of one suggestion after another as a leading idea, or hypothesis , to initiate and guide observation and other operations in collection of factual material;
• the mental elaboration of the idea or supposition as an idea or supposition ( reasoning , in the sense on which reasoning is a part, not the whole, of inference); and
• testing the hypothesis by overt or imaginative action. (Dewey 1933: 106–107; italics in original)

The process of reflective thinking consisting of these phases would be preceded by a perplexed, troubled or confused situation and followed by a cleared-up, unified, resolved situation (Dewey 1933: 106). The term ‘phases’ replaced the term ‘steps’ (Dewey 1910: 72), thus removing the earlier suggestion of an invariant sequence. Variants of the above analysis appeared in (Dewey 1916: 177) and (Dewey 1938: 101–119).

The variant formulations indicate the difficulty of giving a single logical analysis of such a varied process. The process of critical thinking may have a spiral pattern, with the problem being redefined in the light of obstacles to solving it as originally formulated. For example, the person in Transit might have concluded that getting to the appointment at the scheduled time was impossible and have reformulated the problem as that of rescheduling the appointment for a mutually convenient time. Further, defining a problem does not always follow after or lead immediately to an idea of a suggested solution. Nor should it do so, as Dewey himself recognized in describing the physician in Typhoid as avoiding any strong preference for this or that conclusion before getting further information (Dewey 1910: 85; 1933: 170). People with a hypothesis in mind, even one to which they have a very weak commitment, have a so-called “confirmation bias” (Nickerson 1998): they are likely to pay attention to evidence that confirms the hypothesis and to ignore evidence that counts against it or for some competing hypothesis. Detectives, intelligence agencies, and investigators of airplane accidents are well advised to gather relevant evidence systematically and to postpone even tentative adoption of an explanatory hypothesis until the collected evidence rules out with the appropriate degree of certainty all but one explanation. Dewey’s analysis of the critical thinking process can be faulted as well for requiring acceptance or rejection of a possible solution to a defined problem, with no allowance for deciding in the light of the available evidence to suspend judgment. Further, given the great variety of kinds of problems for which reflection is appropriate, there is likely to be variation in its component events. Perhaps the best way to conceptualize the critical thinking process is as a checklist whose component events can occur in a variety of orders, selectively, and more than once. These component events might include (1) noticing a difficulty, (2) defining the problem, (3) dividing the problem into manageable sub-problems, (4) formulating a variety of possible solutions to the problem or sub-problem, (5) determining what evidence is relevant to deciding among possible solutions to the problem or sub-problem, (6) devising a plan of systematic observation or experiment that will uncover the relevant evidence, (7) carrying out the plan of systematic observation or experimentation, (8) noting the results of the systematic observation or experiment, (9) gathering relevant testimony and information from others, (10) judging the credibility of testimony and information gathered from others, (11) drawing conclusions from gathered evidence and accepted testimony, and (12) accepting a solution that the evidence adequately supports (cf. Hitchcock 2017: 485).

Checklist conceptions of the process of critical thinking are open to the objection that they are too mechanical and procedural to fit the multi-dimensional and emotionally charged issues for which critical thinking is urgently needed (Paul 1984). For such issues, a more dialectical process is advocated, in which competing relevant world views are identified, their implications explored, and some sort of creative synthesis attempted.

If one considers the critical thinking process illustrated by the 11 examples, one can identify distinct kinds of mental acts and mental states that form part of it. To distinguish, label and briefly characterize these components is a useful preliminary to identifying abilities, skills, dispositions, attitudes, habits and the like that contribute causally to thinking critically. Identifying such abilities and habits is in turn a useful preliminary to setting educational goals. Setting the goals is in its turn a useful preliminary to designing strategies for helping learners to achieve the goals and to designing ways of measuring the extent to which learners have done so. Such measures provide both feedback to learners on their achievement and a basis for experimental research on the effectiveness of various strategies for educating people to think critically. Let us begin, then, by distinguishing the kinds of mental acts and mental events that can occur in a critical thinking process.

• Observing : One notices something in one’s immediate environment (sudden cooling of temperature in Weather , bubbles forming outside a glass and then going inside in Bubbles , a moving blur in the distance in Blur , a rash in Rash ). Or one notes the results of an experiment or systematic observation (valuables missing in Disorder , no suction without air pressure in Suction pump )
• Feeling : One feels puzzled or uncertain about something (how to get to an appointment on time in Transit , why the diamonds vary in spacing in Diamond ). One wants to resolve this perplexity. One feels satisfaction once one has worked out an answer (to take the subway express in Transit , diamonds closer when needed as a warning in Diamond ).
• Wondering : One formulates a question to be addressed (why bubbles form outside a tumbler taken from hot water in Bubbles , how suction pumps work in Suction pump , what caused the rash in Rash ).
• Imagining : One thinks of possible answers (bus or subway or elevated in Transit , flagpole or ornament or wireless communication aid or direction indicator in Ferryboat , allergic reaction or heat rash in Rash ).
• Inferring : One works out what would be the case if a possible answer were assumed (valuables missing if there has been a burglary in Disorder , earlier start to the rash if it is an allergic reaction to a sulfa drug in Rash ). Or one draws a conclusion once sufficient relevant evidence is gathered (take the subway in Transit , burglary in Disorder , discontinue blood pressure medication and new cream in Rash ).
• Knowledge : One uses stored knowledge of the subject-matter to generate possible answers or to infer what would be expected on the assumption of a particular answer (knowledge of a city’s public transit system in Transit , of the requirements for a flagpole in Ferryboat , of Boyle’s law in Bubbles , of allergic reactions in Rash ).
• Experimenting : One designs and carries out an experiment or a systematic observation to find out whether the results deduced from a possible answer will occur (looking at the location of the flagpole in relation to the pilot’s position in Ferryboat , putting an ice cube on top of a tumbler taken from hot water in Bubbles , measuring the height to which a suction pump will draw water at different elevations in Suction pump , noticing the spacing of diamonds when movement to or from a diamond lane is allowed in Diamond ).
• Consulting : One finds a source of information, gets the information from the source, and makes a judgment on whether to accept it. None of our 11 examples include searching for sources of information. In this respect they are unrepresentative, since most people nowadays have almost instant access to information relevant to answering any question, including many of those illustrated by the examples. However, Candidate includes the activities of extracting information from sources and evaluating its credibility.
• Identifying and analyzing arguments : One notices an argument and works out its structure and content as a preliminary to evaluating its strength. This activity is central to Candidate . It is an important part of a critical thinking process in which one surveys arguments for various positions on an issue.
• Judging : One makes a judgment on the basis of accumulated evidence and reasoning, such as the judgment in Ferryboat that the purpose of the pole is to provide direction to the pilot.
• Deciding : One makes a decision on what to do or on what policy to adopt, as in the decision in Transit to take the subway.

By definition, a person who does something voluntarily is both willing and able to do that thing at that time. Both the willingness and the ability contribute causally to the person’s action, in the sense that the voluntary action would not occur if either (or both) of these were lacking. For example, suppose that one is standing with one’s arms at one’s sides and one voluntarily lifts one’s right arm to an extended horizontal position. One would not do so if one were unable to lift one’s arm, if for example one’s right side was paralyzed as the result of a stroke. Nor would one do so if one were unwilling to lift one’s arm, if for example one were participating in a street demonstration at which a white supremacist was urging the crowd to lift their right arm in a Nazi salute and one were unwilling to express support in this way for the racist Nazi ideology. The same analysis applies to a voluntary mental process of thinking critically. It requires both willingness and ability to think critically, including willingness and ability to perform each of the mental acts that compose the process and to coordinate those acts in a sequence that is directed at resolving the initiating perplexity.

Consider willingness first. We can identify causal contributors to willingness to think critically by considering factors that would cause a person who was able to think critically about an issue nevertheless not to do so (Hamby 2014). For each factor, the opposite condition thus contributes causally to willingness to think critically on a particular occasion. For example, people who habitually jump to conclusions without considering alternatives will not think critically about issues that arise, even if they have the required abilities. The contrary condition of willingness to suspend judgment is thus a causal contributor to thinking critically.

Now consider ability. In contrast to the ability to move one’s arm, which can be completely absent because a stroke has left the arm paralyzed, the ability to think critically is a developed ability, whose absence is not a complete absence of ability to think but absence of ability to think well. We can identify the ability to think well directly, in terms of the norms and standards for good thinking. In general, to be able do well the thinking activities that can be components of a critical thinking process, one needs to know the concepts and principles that characterize their good performance, to recognize in particular cases that the concepts and principles apply, and to apply them. The knowledge, recognition and application may be procedural rather than declarative. It may be domain-specific rather than widely applicable, and in either case may need subject-matter knowledge, sometimes of a deep kind.

Reflections of the sort illustrated by the previous two paragraphs have led scholars to identify the knowledge, abilities and dispositions of a “critical thinker”, i.e., someone who thinks critically whenever it is appropriate to do so. We turn now to these three types of causal contributors to thinking critically. We start with dispositions, since arguably these are the most powerful contributors to being a critical thinker, can be fostered at an early stage of a child’s development, and are susceptible to general improvement (Glaser 1941: 175)

8. Critical Thinking Dispositions

Educational researchers use the term ‘dispositions’ broadly for the habits of mind and attitudes that contribute causally to being a critical thinker. Some writers (e.g., Paul & Elder 2006; Hamby 2014; Bailin & Battersby 2016a) propose to use the term ‘virtues’ for this dimension of a critical thinker. The virtues in question, although they are virtues of character, concern the person’s ways of thinking rather than the person’s ways of behaving towards others. They are not moral virtues but intellectual virtues, of the sort articulated by Zagzebski (1996) and discussed by Turri, Alfano, and Greco (2017).

On a realistic conception, thinking dispositions or intellectual virtues are real properties of thinkers. They are general tendencies, propensities, or inclinations to think in particular ways in particular circumstances, and can be genuinely explanatory (Siegel 1999). Sceptics argue that there is no evidence for a specific mental basis for the habits of mind that contribute to thinking critically, and that it is pedagogically misleading to posit such a basis (Bailin et al. 1999a). Whatever their status, critical thinking dispositions need motivation for their initial formation in a child—motivation that may be external or internal. As children develop, the force of habit will gradually become important in sustaining the disposition (Nieto & Valenzuela 2012). Mere force of habit, however, is unlikely to sustain critical thinking dispositions. Critical thinkers must value and enjoy using their knowledge and abilities to think things through for themselves. They must be committed to, and lovers of, inquiry.

A person may have a critical thinking disposition with respect to only some kinds of issues. For example, one could be open-minded about scientific issues but not about religious issues. Similarly, one could be confident in one’s ability to reason about the theological implications of the existence of evil in the world but not in one’s ability to reason about the best design for a guided ballistic missile.

Facione (1990a: 25) divides “affective dispositions” of critical thinking into approaches to life and living in general and approaches to specific issues, questions or problems. Adapting this distinction, one can usefully divide critical thinking dispositions into initiating dispositions (those that contribute causally to starting to think critically about an issue) and internal dispositions (those that contribute causally to doing a good job of thinking critically once one has started). The two categories are not mutually exclusive. For example, open-mindedness, in the sense of willingness to consider alternative points of view to one’s own, is both an initiating and an internal disposition.

Using the strategy of considering factors that would block people with the ability to think critically from doing so, we can identify as initiating dispositions for thinking critically attentiveness, a habit of inquiry, self-confidence, courage, open-mindedness, willingness to suspend judgment, trust in reason, wanting evidence for one’s beliefs, and seeking the truth. We consider briefly what each of these dispositions amounts to, in each case citing sources that acknowledge them.

• Attentiveness : One will not think critically if one fails to recognize an issue that needs to be thought through. For example, the pedestrian in Weather would not have looked up if he had not noticed that the air was suddenly cooler. To be a critical thinker, then, one needs to be habitually attentive to one’s surroundings, noticing not only what one senses but also sources of perplexity in messages received and in one’s own beliefs and attitudes (Facione 1990a: 25; Facione, Facione, & Giancarlo 2001).
• Habit of inquiry : Inquiry is effortful, and one needs an internal push to engage in it. For example, the student in Bubbles could easily have stopped at idle wondering about the cause of the bubbles rather than reasoning to a hypothesis, then designing and executing an experiment to test it. Thus willingness to think critically needs mental energy and initiative. What can supply that energy? Love of inquiry, or perhaps just a habit of inquiry. Hamby (2015) has argued that willingness to inquire is the central critical thinking virtue, one that encompasses all the others. It is recognized as a critical thinking disposition by Dewey (1910: 29; 1933: 35), Glaser (1941: 5), Ennis (1987: 12; 1991: 8), Facione (1990a: 25), Bailin et al. (1999b: 294), Halpern (1998: 452), and Facione, Facione, & Giancarlo (2001).
• Self-confidence : Lack of confidence in one’s abilities can block critical thinking. For example, if the woman in Rash lacked confidence in her ability to figure things out for herself, she might just have assumed that the rash on her chest was the allergic reaction to her medication against which the pharmacist had warned her. Thus willingness to think critically requires confidence in one’s ability to inquire (Facione 1990a: 25; Facione, Facione, & Giancarlo 2001).
• Courage : Fear of thinking for oneself can stop one from doing it. Thus willingness to think critically requires intellectual courage (Paul & Elder 2006: 16).
• Open-mindedness : A dogmatic attitude will impede thinking critically. For example, a person who adheres rigidly to a “pro-choice” position on the issue of the legal status of induced abortion is likely to be unwilling to consider seriously the issue of when in its development an unborn child acquires a moral right to life. Thus willingness to think critically requires open-mindedness, in the sense of a willingness to examine questions to which one already accepts an answer but which further evidence or reasoning might cause one to answer differently (Dewey 1933; Facione 1990a; Ennis 1991; Bailin et al. 1999b; Halpern 1998, Facione, Facione, & Giancarlo 2001). Paul (1981) emphasizes open-mindedness about alternative world-views, and recommends a dialectical approach to integrating such views as central to what he calls “strong sense” critical thinking. In three studies, Haran, Ritov, & Mellers (2013) found that actively open-minded thinking, including “the tendency to weigh new evidence against a favored belief, to spend sufficient time on a problem before giving up, and to consider carefully the opinions of others in forming one’s own”, led study participants to acquire information and thus to make accurate estimations.
• Willingness to suspend judgment : Premature closure on an initial solution will block critical thinking. Thus willingness to think critically requires a willingness to suspend judgment while alternatives are explored (Facione 1990a; Ennis 1991; Halpern 1998).
• Trust in reason : Since distrust in the processes of reasoned inquiry will dissuade one from engaging in it, trust in them is an initiating critical thinking disposition (Facione 1990a, 25; Bailin et al. 1999b: 294; Facione, Facione, & Giancarlo 2001; Paul & Elder 2006). In reaction to an allegedly exclusive emphasis on reason in critical thinking theory and pedagogy, Thayer-Bacon (2000) argues that intuition, imagination, and emotion have important roles to play in an adequate conception of critical thinking that she calls “constructive thinking”. From her point of view, critical thinking requires trust not only in reason but also in intuition, imagination, and emotion.
• Seeking the truth : If one does not care about the truth but is content to stick with one’s initial bias on an issue, then one will not think critically about it. Seeking the truth is thus an initiating critical thinking disposition (Bailin et al. 1999b: 294; Facione, Facione, & Giancarlo 2001). A disposition to seek the truth is implicit in more specific critical thinking dispositions, such as trying to be well-informed, considering seriously points of view other than one’s own, looking for alternatives, suspending judgment when the evidence is insufficient, and adopting a position when the evidence supporting it is sufficient.

Some of the initiating dispositions, such as open-mindedness and willingness to suspend judgment, are also internal critical thinking dispositions, in the sense of mental habits or attitudes that contribute causally to doing a good job of critical thinking once one starts the process. But there are many other internal critical thinking dispositions. Some of them are parasitic on one’s conception of good thinking. For example, it is constitutive of good thinking about an issue to formulate the issue clearly and to maintain focus on it. For this purpose, one needs not only the corresponding ability but also the corresponding disposition. Ennis (1991: 8) describes it as the disposition “to determine and maintain focus on the conclusion or question”, Facione (1990a: 25) as “clarity in stating the question or concern”. Other internal dispositions are motivators to continue or adjust the critical thinking process, such as willingness to persist in a complex task and willingness to abandon nonproductive strategies in an attempt to self-correct (Halpern 1998: 452). For a list of identified internal critical thinking dispositions, see the Supplement on Internal Critical Thinking Dispositions .

Some theorists postulate skills, i.e., acquired abilities, as operative in critical thinking. It is not obvious, however, that a good mental act is the exercise of a generic acquired skill. Inferring an expected time of arrival, as in Transit , has some generic components but also uses non-generic subject-matter knowledge. Bailin et al. (1999a) argue against viewing critical thinking skills as generic and discrete, on the ground that skilled performance at a critical thinking task cannot be separated from knowledge of concepts and from domain-specific principles of good thinking. Talk of skills, they concede, is unproblematic if it means merely that a person with critical thinking skills is capable of intelligent performance.

Despite such scepticism, theorists of critical thinking have listed as general contributors to critical thinking what they variously call abilities (Glaser 1941; Ennis 1962, 1991), skills (Facione 1990a; Halpern 1998) or competencies (Fisher & Scriven 1997). Amalgamating these lists would produce a confusing and chaotic cornucopia of more than 50 possible educational objectives, with only partial overlap among them. It makes sense instead to try to understand the reasons for the multiplicity and diversity, and to make a selection according to one’s own reasons for singling out abilities to be developed in a critical thinking curriculum. Two reasons for diversity among lists of critical thinking abilities are the underlying conception of critical thinking and the envisaged educational level. Appraisal-only conceptions, for example, involve a different suite of abilities than constructive-only conceptions. Some lists, such as those in (Glaser 1941), are put forward as educational objectives for secondary school students, whereas others are proposed as objectives for college students (e.g., Facione 1990a).

The abilities described in the remaining paragraphs of this section emerge from reflection on the general abilities needed to do well the thinking activities identified in section 6 as components of the critical thinking process described in section 5 . The derivation of each collection of abilities is accompanied by citation of sources that list such abilities and of standardized tests that claim to test them.

Observational abilities : Careful and accurate observation sometimes requires specialist expertise and practice, as in the case of observing birds and observing accident scenes. However, there are general abilities of noticing what one’s senses are picking up from one’s environment and of being able to articulate clearly and accurately to oneself and others what one has observed. It helps in exercising them to be able to recognize and take into account factors that make one’s observation less trustworthy, such as prior framing of the situation, inadequate time, deficient senses, poor observation conditions, and the like. It helps as well to be skilled at taking steps to make one’s observation more trustworthy, such as moving closer to get a better look, measuring something three times and taking the average, and checking what one thinks one is observing with someone else who is in a good position to observe it. It also helps to be skilled at recognizing respects in which one’s report of one’s observation involves inference rather than direct observation, so that one can then consider whether the inference is justified. These abilities come into play as well when one thinks about whether and with what degree of confidence to accept an observation report, for example in the study of history or in a criminal investigation or in assessing news reports. Observational abilities show up in some lists of critical thinking abilities (Ennis 1962: 90; Facione 1990a: 16; Ennis 1991: 9). There are items testing a person’s ability to judge the credibility of observation reports in the Cornell Critical Thinking Tests, Levels X and Z (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005). Norris and King (1983, 1985, 1990a, 1990b) is a test of ability to appraise observation reports.

Emotional abilities : The emotions that drive a critical thinking process are perplexity or puzzlement, a wish to resolve it, and satisfaction at achieving the desired resolution. Children experience these emotions at an early age, without being trained to do so. Education that takes critical thinking as a goal needs only to channel these emotions and to make sure not to stifle them. Collaborative critical thinking benefits from ability to recognize one’s own and others’ emotional commitments and reactions.

Questioning abilities : A critical thinking process needs transformation of an inchoate sense of perplexity into a clear question. Formulating a question well requires not building in questionable assumptions, not prejudging the issue, and using language that in context is unambiguous and precise enough (Ennis 1962: 97; 1991: 9).

Imaginative abilities : Thinking directed at finding the correct causal explanation of a general phenomenon or particular event requires an ability to imagine possible explanations. Thinking about what policy or plan of action to adopt requires generation of options and consideration of possible consequences of each option. Domain knowledge is required for such creative activity, but a general ability to imagine alternatives is helpful and can be nurtured so as to become easier, quicker, more extensive, and deeper (Dewey 1910: 34–39; 1933: 40–47). Facione (1990a) and Halpern (1998) include the ability to imagine alternatives as a critical thinking ability.

Inferential abilities : The ability to draw conclusions from given information, and to recognize with what degree of certainty one’s own or others’ conclusions follow, is universally recognized as a general critical thinking ability. All 11 examples in section 2 of this article include inferences, some from hypotheses or options (as in Transit , Ferryboat and Disorder ), others from something observed (as in Weather and Rash ). None of these inferences is formally valid. Rather, they are licensed by general, sometimes qualified substantive rules of inference (Toulmin 1958) that rest on domain knowledge—that a bus trip takes about the same time in each direction, that the terminal of a wireless telegraph would be located on the highest possible place, that sudden cooling is often followed by rain, that an allergic reaction to a sulfa drug generally shows up soon after one starts taking it. It is a matter of controversy to what extent the specialized ability to deduce conclusions from premisses using formal rules of inference is needed for critical thinking. Dewey (1933) locates logical forms in setting out the products of reflection rather than in the process of reflection. Ennis (1981a), on the other hand, maintains that a liberally-educated person should have the following abilities: to translate natural-language statements into statements using the standard logical operators, to use appropriately the language of necessary and sufficient conditions, to deal with argument forms and arguments containing symbols, to determine whether in virtue of an argument’s form its conclusion follows necessarily from its premisses, to reason with logically complex propositions, and to apply the rules and procedures of deductive logic. Inferential abilities are recognized as critical thinking abilities by Glaser (1941: 6), Facione (1990a: 9), Ennis (1991: 9), Fisher & Scriven (1997: 99, 111), and Halpern (1998: 452). Items testing inferential abilities constitute two of the five subtests of the Watson Glaser Critical Thinking Appraisal (Watson & Glaser 1980a, 1980b, 1994), two of the four sections in the Cornell Critical Thinking Test Level X (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005), three of the seven sections in the Cornell Critical Thinking Test Level Z (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005), 11 of the 34 items on Forms A and B of the California Critical Thinking Skills Test (Facione 1990b, 1992), and a high but variable proportion of the 25 selected-response questions in the Collegiate Learning Assessment (Council for Aid to Education 2017).

Experimenting abilities : Knowing how to design and execute an experiment is important not just in scientific research but also in everyday life, as in Rash . Dewey devoted a whole chapter of his How We Think (1910: 145–156; 1933: 190–202) to the superiority of experimentation over observation in advancing knowledge. Experimenting abilities come into play at one remove in appraising reports of scientific studies. Skill in designing and executing experiments includes the acknowledged abilities to appraise evidence (Glaser 1941: 6), to carry out experiments and to apply appropriate statistical inference techniques (Facione 1990a: 9), to judge inductions to an explanatory hypothesis (Ennis 1991: 9), and to recognize the need for an adequately large sample size (Halpern 1998). The Cornell Critical Thinking Test Level Z (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005) includes four items (out of 52) on experimental design. The Collegiate Learning Assessment (Council for Aid to Education 2017) makes room for appraisal of study design in both its performance task and its selected-response questions.

Consulting abilities : Skill at consulting sources of information comes into play when one seeks information to help resolve a problem, as in Candidate . Ability to find and appraise information includes ability to gather and marshal pertinent information (Glaser 1941: 6), to judge whether a statement made by an alleged authority is acceptable (Ennis 1962: 84), to plan a search for desired information (Facione 1990a: 9), and to judge the credibility of a source (Ennis 1991: 9). Ability to judge the credibility of statements is tested by 24 items (out of 76) in the Cornell Critical Thinking Test Level X (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005) and by four items (out of 52) in the Cornell Critical Thinking Test Level Z (Ennis & Millman 1971; Ennis, Millman, & Tomko 1985, 2005). The College Learning Assessment’s performance task requires evaluation of whether information in documents is credible or unreliable (Council for Aid to Education 2017).

Argument analysis abilities : The ability to identify and analyze arguments contributes to the process of surveying arguments on an issue in order to form one’s own reasoned judgment, as in Candidate . The ability to detect and analyze arguments is recognized as a critical thinking skill by Facione (1990a: 7–8), Ennis (1991: 9) and Halpern (1998). Five items (out of 34) on the California Critical Thinking Skills Test (Facione 1990b, 1992) test skill at argument analysis. The College Learning Assessment (Council for Aid to Education 2017) incorporates argument analysis in its selected-response tests of critical reading and evaluation and of critiquing an argument.

Judging skills and deciding skills : Skill at judging and deciding is skill at recognizing what judgment or decision the available evidence and argument supports, and with what degree of confidence. It is thus a component of the inferential skills already discussed.

Lists and tests of critical thinking abilities often include two more abilities: identifying assumptions and constructing and evaluating definitions.

In addition to dispositions and abilities, critical thinking needs knowledge: of critical thinking concepts, of critical thinking principles, and of the subject-matter of the thinking.

We can derive a short list of concepts whose understanding contributes to critical thinking from the critical thinking abilities described in the preceding section. Observational abilities require an understanding of the difference between observation and inference. Questioning abilities require an understanding of the concepts of ambiguity and vagueness. Inferential abilities require an understanding of the difference between conclusive and defeasible inference (traditionally, between deduction and induction), as well as of the difference between necessary and sufficient conditions. Experimenting abilities require an understanding of the concepts of hypothesis, null hypothesis, assumption and prediction, as well as of the concept of statistical significance and of its difference from importance. They also require an understanding of the difference between an experiment and an observational study, and in particular of the difference between a randomized controlled trial, a prospective correlational study and a retrospective (case-control) study. Argument analysis abilities require an understanding of the concepts of argument, premiss, assumption, conclusion and counter-consideration. Additional critical thinking concepts are proposed by Bailin et al. (1999b: 293), Fisher & Scriven (1997: 105–106), Black (2012), and Blair (2021).

According to Glaser (1941: 25), ability to think critically requires knowledge of the methods of logical inquiry and reasoning. If we review the list of abilities in the preceding section, however, we can see that some of them can be acquired and exercised merely through practice, possibly guided in an educational setting, followed by feedback. Searching intelligently for a causal explanation of some phenomenon or event requires that one consider a full range of possible causal contributors, but it seems more important that one implements this principle in one’s practice than that one is able to articulate it. What is important is “operational knowledge” of the standards and principles of good thinking (Bailin et al. 1999b: 291–293). But the development of such critical thinking abilities as designing an experiment or constructing an operational definition can benefit from learning their underlying theory. Further, explicit knowledge of quirks of human thinking seems useful as a cautionary guide. Human memory is not just fallible about details, as people learn from their own experiences of misremembering, but is so malleable that a detailed, clear and vivid recollection of an event can be a total fabrication (Loftus 2017). People seek or interpret evidence in ways that are partial to their existing beliefs and expectations, often unconscious of their “confirmation bias” (Nickerson 1998). Not only are people subject to this and other cognitive biases (Kahneman 2011), of which they are typically unaware, but it may be counter-productive for one to make oneself aware of them and try consciously to counteract them or to counteract social biases such as racial or sexual stereotypes (Kenyon & Beaulac 2014). It is helpful to be aware of these facts and of the superior effectiveness of blocking the operation of biases—for example, by making an immediate record of one’s observations, refraining from forming a preliminary explanatory hypothesis, blind refereeing, double-blind randomized trials, and blind grading of students’ work. It is also helpful to be aware of the prevalence of “noise” (unwanted unsystematic variability of judgments), of how to detect noise (through a noise audit), and of how to reduce noise: make accuracy the goal, think statistically, break a process of arriving at a judgment into independent tasks, resist premature intuitions, in a group get independent judgments first, favour comparative judgments and scales (Kahneman, Sibony, & Sunstein 2021). It is helpful as well to be aware of the concept of “bounded rationality” in decision-making and of the related distinction between “satisficing” and optimizing (Simon 1956; Gigerenzer 2001).

Critical thinking about an issue requires substantive knowledge of the domain to which the issue belongs. Critical thinking abilities are not a magic elixir that can be applied to any issue whatever by somebody who has no knowledge of the facts relevant to exploring that issue. For example, the student in Bubbles needed to know that gases do not penetrate solid objects like a glass, that air expands when heated, that the volume of an enclosed gas varies directly with its temperature and inversely with its pressure, and that hot objects will spontaneously cool down to the ambient temperature of their surroundings unless kept hot by insulation or a source of heat. Critical thinkers thus need a rich fund of subject-matter knowledge relevant to the variety of situations they encounter. This fact is recognized in the inclusion among critical thinking dispositions of a concern to become and remain generally well informed.

Experimental educational interventions, with control groups, have shown that education can improve critical thinking skills and dispositions, as measured by standardized tests. For information about these tests, see the Supplement on Assessment .

What educational methods are most effective at developing the dispositions, abilities and knowledge of a critical thinker? In a comprehensive meta-analysis of experimental and quasi-experimental studies of strategies for teaching students to think critically, Abrami et al. (2015) found that dialogue, anchored instruction, and mentoring each increased the effectiveness of the educational intervention, and that they were most effective when combined. They also found that in these studies a combination of separate instruction in critical thinking with subject-matter instruction in which students are encouraged to think critically was more effective than either by itself. However, the difference was not statistically significant; that is, it might have arisen by chance.

Most of these studies lack the longitudinal follow-up required to determine whether the observed differential improvements in critical thinking abilities or dispositions continue over time, for example until high school or college graduation. For details on studies of methods of developing critical thinking skills and dispositions, see the Supplement on Educational Methods .

12. Controversies

Scholars have denied the generalizability of critical thinking abilities across subject domains, have alleged bias in critical thinking theory and pedagogy, and have investigated the relationship of critical thinking to other kinds of thinking.

McPeck (1981) attacked the thinking skills movement of the 1970s, including the critical thinking movement. He argued that there are no general thinking skills, since thinking is always thinking about some subject-matter. It is futile, he claimed, for schools and colleges to teach thinking as if it were a separate subject. Rather, teachers should lead their pupils to become autonomous thinkers by teaching school subjects in a way that brings out their cognitive structure and that encourages and rewards discussion and argument. As some of his critics (e.g., Paul 1985; Siegel 1985) pointed out, McPeck’s central argument needs elaboration, since it has obvious counter-examples in writing and speaking, for which (up to a certain level of complexity) there are teachable general abilities even though they are always about some subject-matter. To make his argument convincing, McPeck needs to explain how thinking differs from writing and speaking in a way that does not permit useful abstraction of its components from the subject-matters with which it deals. He has not done so. Nevertheless, his position that the dispositions and abilities of a critical thinker are best developed in the context of subject-matter instruction is shared by many theorists of critical thinking, including Dewey (1910, 1933), Glaser (1941), Passmore (1980), Weinstein (1990), Bailin et al. (1999b), and Willingham (2019).

McPeck’s challenge prompted reflection on the extent to which critical thinking is subject-specific. McPeck argued for a strong subject-specificity thesis, according to which it is a conceptual truth that all critical thinking abilities are specific to a subject. (He did not however extend his subject-specificity thesis to critical thinking dispositions. In particular, he took the disposition to suspend judgment in situations of cognitive dissonance to be a general disposition.) Conceptual subject-specificity is subject to obvious counter-examples, such as the general ability to recognize confusion of necessary and sufficient conditions. A more modest thesis, also endorsed by McPeck, is epistemological subject-specificity, according to which the norms of good thinking vary from one field to another. Epistemological subject-specificity clearly holds to a certain extent; for example, the principles in accordance with which one solves a differential equation are quite different from the principles in accordance with which one determines whether a painting is a genuine Picasso. But the thesis suffers, as Ennis (1989) points out, from vagueness of the concept of a field or subject and from the obvious existence of inter-field principles, however broadly the concept of a field is construed. For example, the principles of hypothetico-deductive reasoning hold for all the varied fields in which such reasoning occurs. A third kind of subject-specificity is empirical subject-specificity, according to which as a matter of empirically observable fact a person with the abilities and dispositions of a critical thinker in one area of investigation will not necessarily have them in another area of investigation.

The thesis of empirical subject-specificity raises the general problem of transfer. If critical thinking abilities and dispositions have to be developed independently in each school subject, how are they of any use in dealing with the problems of everyday life and the political and social issues of contemporary society, most of which do not fit into the framework of a traditional school subject? Proponents of empirical subject-specificity tend to argue that transfer is more likely to occur if there is critical thinking instruction in a variety of domains, with explicit attention to dispositions and abilities that cut across domains. But evidence for this claim is scanty. There is a need for well-designed empirical studies that investigate the conditions that make transfer more likely.

It is common ground in debates about the generality or subject-specificity of critical thinking dispositions and abilities that critical thinking about any topic requires background knowledge about the topic. For example, the most sophisticated understanding of the principles of hypothetico-deductive reasoning is of no help unless accompanied by some knowledge of what might be plausible explanations of some phenomenon under investigation.

Critics have objected to bias in the theory, pedagogy and practice of critical thinking. Commentators (e.g., Alston 1995; Ennis 1998) have noted that anyone who takes a position has a bias in the neutral sense of being inclined in one direction rather than others. The critics, however, are objecting to bias in the pejorative sense of an unjustified favoring of certain ways of knowing over others, frequently alleging that the unjustly favoured ways are those of a dominant sex or culture (Bailin 1995). These ways favour:

• reinforcement of egocentric and sociocentric biases over dialectical engagement with opposing world-views (Paul 1981, 1984; Warren 1998)
• distancing from the object of inquiry over closeness to it (Martin 1992; Thayer-Bacon 1992)
• indifference to the situation of others over care for them (Martin 1992)
• orientation to thought over orientation to action (Martin 1992)
• being reasonable over caring to understand people’s ideas (Thayer-Bacon 1993)
• being neutral and objective over being embodied and situated (Thayer-Bacon 1995a)
• doubting over believing (Thayer-Bacon 1995b)
• reason over emotion, imagination and intuition (Thayer-Bacon 2000)
• solitary thinking over collaborative thinking (Thayer-Bacon 2000)
• written and spoken assignments over other forms of expression (Alston 2001)
• attention to written and spoken communications over attention to human problems (Alston 2001)
• winning debates in the public sphere over making and understanding meaning (Alston 2001)

A common thread in this smorgasbord of accusations is dissatisfaction with focusing on the logical analysis and evaluation of reasoning and arguments. While these authors acknowledge that such analysis and evaluation is part of critical thinking and should be part of its conceptualization and pedagogy, they insist that it is only a part. Paul (1981), for example, bemoans the tendency of atomistic teaching of methods of analyzing and evaluating arguments to turn students into more able sophists, adept at finding fault with positions and arguments with which they disagree but even more entrenched in the egocentric and sociocentric biases with which they began. Martin (1992) and Thayer-Bacon (1992) cite with approval the self-reported intimacy with their subject-matter of leading researchers in biology and medicine, an intimacy that conflicts with the distancing allegedly recommended in standard conceptions and pedagogy of critical thinking. Thayer-Bacon (2000) contrasts the embodied and socially embedded learning of her elementary school students in a Montessori school, who used their imagination, intuition and emotions as well as their reason, with conceptions of critical thinking as

thinking that is used to critique arguments, offer justifications, and make judgments about what are the good reasons, or the right answers. (Thayer-Bacon 2000: 127–128)

Alston (2001) reports that her students in a women’s studies class were able to see the flaws in the Cinderella myth that pervades much romantic fiction but in their own romantic relationships still acted as if all failures were the woman’s fault and still accepted the notions of love at first sight and living happily ever after. Students, she writes, should

be able to connect their intellectual critique to a more affective, somatic, and ethical account of making risky choices that have sexist, racist, classist, familial, sexual, or other consequences for themselves and those both near and far… critical thinking that reads arguments, texts, or practices merely on the surface without connections to feeling/desiring/doing or action lacks an ethical depth that should infuse the difference between mere cognitive activity and something we want to call critical thinking. (Alston 2001: 34)

Some critics portray such biases as unfair to women. Thayer-Bacon (1992), for example, has charged modern critical thinking theory with being sexist, on the ground that it separates the self from the object and causes one to lose touch with one’s inner voice, and thus stigmatizes women, who (she asserts) link self to object and listen to their inner voice. Her charge does not imply that women as a group are on average less able than men to analyze and evaluate arguments. Facione (1990c) found no difference by sex in performance on his California Critical Thinking Skills Test. Kuhn (1991: 280–281) found no difference by sex in either the disposition or the competence to engage in argumentative thinking.

The critics propose a variety of remedies for the biases that they allege. In general, they do not propose to eliminate or downplay critical thinking as an educational goal. Rather, they propose to conceptualize critical thinking differently and to change its pedagogy accordingly. Their pedagogical proposals arise logically from their objections. They can be summarized as follows:

• Focus on argument networks with dialectical exchanges reflecting contesting points of view rather than on atomic arguments, so as to develop “strong sense” critical thinking that transcends egocentric and sociocentric biases (Paul 1981, 1984).
• Foster closeness to the subject-matter and feeling connected to others in order to inform a humane democracy (Martin 1992).
• Develop “constructive thinking” as a social activity in a community of physically embodied and socially embedded inquirers with personal voices who value not only reason but also imagination, intuition and emotion (Thayer-Bacon 2000).
• In developing critical thinking in school subjects, treat as important neither skills nor dispositions but opening worlds of meaning (Alston 2001).
• Attend to the development of critical thinking dispositions as well as skills, and adopt the “critical pedagogy” practised and advocated by Freire (1968 [1970]) and hooks (1994) (Dalgleish, Girard, & Davies 2017).

A common thread in these proposals is treatment of critical thinking as a social, interactive, personally engaged activity like that of a quilting bee or a barn-raising (Thayer-Bacon 2000) rather than as an individual, solitary, distanced activity symbolized by Rodin’s The Thinker . One can get a vivid description of education with the former type of goal from the writings of bell hooks (1994, 2010). Critical thinking for her is open-minded dialectical exchange across opposing standpoints and from multiple perspectives, a conception similar to Paul’s “strong sense” critical thinking (Paul 1981). She abandons the structure of domination in the traditional classroom. In an introductory course on black women writers, for example, she assigns students to write an autobiographical paragraph about an early racial memory, then to read it aloud as the others listen, thus affirming the uniqueness and value of each voice and creating a communal awareness of the diversity of the group’s experiences (hooks 1994: 84). Her “engaged pedagogy” is thus similar to the “freedom under guidance” implemented in John Dewey’s Laboratory School of Chicago in the late 1890s and early 1900s. It incorporates the dialogue, anchored instruction, and mentoring that Abrami (2015) found to be most effective in improving critical thinking skills and dispositions.

What is the relationship of critical thinking to problem solving, decision-making, higher-order thinking, creative thinking, and other recognized types of thinking? One’s answer to this question obviously depends on how one defines the terms used in the question. If critical thinking is conceived broadly to cover any careful thinking about any topic for any purpose, then problem solving and decision making will be kinds of critical thinking, if they are done carefully. Historically, ‘critical thinking’ and ‘problem solving’ were two names for the same thing. If critical thinking is conceived more narrowly as consisting solely of appraisal of intellectual products, then it will be disjoint with problem solving and decision making, which are constructive.

Bloom’s taxonomy of educational objectives used the phrase “intellectual abilities and skills” for what had been labeled “critical thinking” by some, “reflective thinking” by Dewey and others, and “problem solving” by still others (Bloom et al. 1956: 38). Thus, the so-called “higher-order thinking skills” at the taxonomy’s top levels of analysis, synthesis and evaluation are just critical thinking skills, although they do not come with general criteria for their assessment (Ennis 1981b). The revised version of Bloom’s taxonomy (Anderson et al. 2001) likewise treats critical thinking as cutting across those types of cognitive process that involve more than remembering (Anderson et al. 2001: 269–270). For details, see the Supplement on History .

As to creative thinking, it overlaps with critical thinking (Bailin 1987, 1988). Thinking about the explanation of some phenomenon or event, as in Ferryboat , requires creative imagination in constructing plausible explanatory hypotheses. Likewise, thinking about a policy question, as in Candidate , requires creativity in coming up with options. Conversely, creativity in any field needs to be balanced by critical appraisal of the draft painting or novel or mathematical theory.

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Argumentation, Evidence Evaluation and Critical Thinking

• First Online: 23 November 2011
• pp 1001–1015

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• María Pilar Jiménez-Aleixandre 4 &
• Blanca Puig 4  

Part of the book series: Springer International Handbooks of Education ((SIHE,volume 24))

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This chapter addresses the relationships between argumentation and critical thinking. The underlying questions are how argumentation supports the capacity to discriminate between claims justified by evidence and mere opinion, and how argumentation can contribute to two types of objectives related to learning science and to citizenship. First, various meanings for critical thinking in different communities are reviewed. Then, we propose our characterisation of critical thinking, which assumes that evidence evaluation is an essential component, but that there are other components related to the capacities of reflecting on the world around us and of participating in it (e.g. developing an independent opinion, including challenging the ideas of one’s own community). This characterisation draws both from the notion of commitment to evidence and from critical theorists. Using this frame, the chapter examines the contributions of argumentation in science education to the components of critical thinking, and also discusses the evaluation of evidence and the different factors influencing or even hampering it. The chapter concludes with consideration of the development of critical thinking in the science classroom.

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Acknowledgements

This work was supported by the Spanish Ministerio de Educación y Ciencia (MEC), partly funded by the European Regional Development Fund (ERDF), code SEJ2006-15589-C02-01/EDUC. The authors are grateful to Glen Aikenhead for his valuable feedback on the first draft.

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Jiménez-Aleixandre, M.P., Puig, B. (2012). Argumentation, Evidence Evaluation and Critical Thinking. In: Fraser, B., Tobin, K., McRobbie, C. (eds) Second International Handbook of Science Education. Springer International Handbooks of Education, vol 24. Springer, Dordrecht. https://doi.org/10.1007/978-1-4020-9041-7_66

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Critical thinking in healthcare and education

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• Jonathan M Sharples , professor 1 ,
• Andrew D Oxman , research director 2 ,
• Kamal R Mahtani , clinical lecturer 3 ,
• Iain Chalmers , coordinator 4 ,
• Sandy Oliver , professor 1 ,
• Kevan Collins , chief executive 5 ,
• Astrid Austvoll-Dahlgren , senior researcher 2 ,
• Tammy Hoffmann , professor 6
• 1 EPPI-Centre, UCL Department of Social Science, London, UK
• 2 Global Health Unit, Norwegian Institute of Public Health, Oslo, Norway
• 3 Centre for Evidence-Based Medicine, Oxford University, Oxford, UK
• 4 James Lind Initiative, Oxford, UK
• 5 Education Endowment Foundation, London, UK
• 6 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Australia
• Correspondence to: J M Sharples Jonathan.Sharples{at}eefoundation.org.uk

Critical thinking is just one skill crucial to evidence based practice in healthcare and education, write Jonathan Sharples and colleagues , who see exciting opportunities for cross sector collaboration

Imagine you are a primary care doctor. A patient comes into your office with acute, atypical chest pain. Immediately you consider the patient’s sex and age, and you begin to think about what questions to ask and what diagnoses and diagnostic tests to consider. You will also need to think about what treatments to consider and how to communicate with the patient and potentially with the patient’s family and other healthcare providers. Some of what you do will be done reflexively, with little explicit thought, but caring for most patients also requires you to think critically about what you are going to do.

Critical thinking, the ability to think clearly and rationally about what to do or what to believe, is essential for the practice of medicine. Few doctors are likely to argue with this. Yet, until recently, the UK regulator the General Medical Council and similar bodies in North America did not mention “critical thinking” anywhere in their standards for licensing and accreditation, 1 and critical thinking is not explicitly taught or assessed in most education programmes for health professionals. 2

Moreover, although more than 2800 articles indexed by PubMed have “critical thinking” in the title or abstract, most are about nursing. We argue that it is important for clinicians and patients to learn to think critically and that the teaching and learning of these skills should be considered explicitly. Given the shared interest in critical thinking with broader education, we also highlight why healthcare and education professionals and researchers need to work together to enable people to think critically about the health choices they make throughout life.

Essential skills for doctors and patients

Critical thinking is not a new concept in education: at the beginning of the last century the US educational reformer John Dewey identified the need to help students “to think well.” 3 Critical thinking encompasses a broad set of skills and dispositions, including cognitive skills (such as analysis, inference, and self regulation); approaches to specific questions or problems (orderliness, diligence, and reasonableness); and approaches to life in general (inquisitiveness, concern with being well informed, and open mindedness). 4

An increasing body of evidence highlights that developing critical thinking skills can benefit academic outcomes as well as wider reasoning and problem solving capabilities. 5 For example, the Thinking, Doing, Talking Science programme trains teachers in a repertoire of strategies that encourage pupils to use critical thinking skills in primary school science lessons. An independently conducted randomised trial of this approach found that it had a positive impact on pupils’ science attainment, with signs that it was particularly beneficial for pupils from poorer families. 6

In medicine, increasing attention has been paid to “critical appraisal” in the past 40 years. Critical appraisal is a subset of critical thinking that focuses on how to use research evidence to inform health decisions. 7 8 9 The need for critical appraisal in medicine was recognised at least 75 years ago, 10 and critical appraisal has been recognised for some decades as an essential competency for healthcare professionals. 11 The General Medical Council’s Good Medical Practice guidance includes the need for doctors to be able to “provide effective treatments based on the best available evidence.” 12

If patients and the public are to make well informed health choices, they must also be able to assess the reliability of health claims and information. This is something that most people struggle to do, and it is becoming increasingly important because patients are taking on a bigger role in managing their health and making healthcare decisions, 13 while needing to cope with more and more health information, much of which is not reliable. 14 15 16 17

Teaching critical thinking

Although critical thinking skills are given limited explicit attention in standards for medical education, they are included as a key competency in most frameworks for national curriculums for primary and secondary schools in many countries. 18 Nonetheless, much health and science education, and education generally, still tends towards rote learning rather than the promotion of critical thinking. 19 20 This matters because the ability to think critically is an essential life skill relevant to decision making in many circumstances. The capacity to think critically is, like a lot of learning, developed in school and the home: parental influence creates advantage for pupils who live in homes where they are encouraged to think and talk about what they are doing. This, importantly, goes beyond simply completing tasks to creating deeper understanding of learning processes. As such, the “critical thinking gap” between children from disadvantaged communities and their more advantaged peers requires attention as early as possible.

Although it is possible to teach critical thinking to adults, it is likely to be more productive if the grounds for this have been laid down in an educational environment early in life, starting in primary school. Erroneous beliefs, attitudes, and behaviours developed during childhood may be difficult to change later. 21 22 This also applies to medical education and to health professionals. It becomes increasingly difficult to teach these skills without a foundation to build on and adequate time to learn them.

Strategies for teaching students to think critically have been evaluated in health and medical education; in science, technology, engineering, and maths; and in other subjects. 23 These studies suggest that critical thinking skills can be taught and that in the absence of explicit teaching of critical thinking, important deficiencies emerge in the abilities of students to make sound judgments. In healthcare studies, many medical students score poorly on tests that measure the ability to think critically , and the ability to think critically is correlated with academic success. 24 25

Evaluations of strategies for teaching critical thinking in medicine have focused primarily on critical appraisal skills as part of evidence based healthcare. An overview of systematic reviews of these studies suggests that improving evidence based healthcare competencies is likely to require multifaceted, clinically integrated approaches that include assessment. 26

Cross sector collaboration

Informed Health Choices, an international project aiming to improve decision making, shows the opportunities and benefits of cross sector collaboration between education and health. 27 This project has brought together people working in education and healthcare to develop a curriculum and learning resources for critical thinking about any action that is claimed to improve health. It aims to develop, identify, and promote the use of effective learning resources, beginning at primary school, to help people to make well informed choices as patients and health professionals, and well informed decisions as citizens and policy makers.

The project has drawn on several approaches used in education, including the development of a “spiral curriculum,” measurement tools, and the design of learning resources. A spiral curriculum begins with determining what people should know and be able to do, and outlines where they should begin and how they should progress to reach these goals. The basic ideas are revisited repeatedly, building on them until the student has grasped a deep understanding of the concepts. 28 29 The project has also drawn on educational research and methods to develop reliable and valid tools for measuring the extent to which those goals have been achieved. 30 31 32 The development of learning resources to teach these skills has been informed by educational research, including educational psychology, motivational psychology, and research and methods for developing learning games. 33 34 35 It has also built on the traditions of clinical epidemiology and evidence based medicine to identify the key concepts required to assess health claims. 29

It is difficult to teach critical thinking abstractly, so focusing on health may have advantages beyond the public health benefits of increasing health literacy. 36 Nearly everyone is interested in health, including children, making it easy to engage learners. It is also immediately relevant to students. As reported by one 10 year old in a school that piloted primary school resources, this is about “things we might actually use instead of things we might use when we are all grown up and by then we’ll forget.” Although the current evaluation of the project is focusing on outcomes relating to appraisal of treatment claims, if the intervention shows promise the next step could be to explore how these skills translate to wider educational contexts and outcomes.

Beyond critical thinking

Exciting opportunities for cross sector collaboration are emerging between healthcare and education. Although critical thinking is a useful example of this, other themes cross the education and healthcare domains, including nutrition, exercise, educational neuroscience, learning disabilities and special education needs, and mental health.

In addition to shared topics, several common methodological and conceptual issues also provide opportunities for sharing ideas and innovations and learning from mistakes and successes. For example, the Education Endowment Foundation is the UK government’s What Works Centre for education, aiming to improve evidence based decision making. Discussions hosted by the foundation are exploring how methods to develop guidelines in healthcare can be adapted and applied in education and other sectors.

Similarly, the foundation’s universal use of independent evaluation for teaching and learning interventions is an approach that should be explored, adapted, and applied in healthcare. Since the development and evaluation of educational interventions are separated, evaluators have no vested interested in the results of the assessment, all results are published, and bias and spin in how results are analysed and presented are reduced. By contrast, industry sponsorship of drug and device studies consistently produces results that favour the manufacturer. 37

Another example of joint working between educators and health is the Best Evidence Medical Education Collaboration, an international collaboration focused on improving education of health professionals. 38 And in the UK, the Centre for Evidence Based Medicine coordinates Evidence in School Teaching (Einstein), a project that supports introducing evidence based medicine as part of wider science activities in schools. 39 It aims to engage students, teachers, and the public in evidence based medicine and develop critical thinking to assess health claims and make better choices.

Collaboration has also been important in the development of the Critical Thinking and Appraisal Resource Library (CARL), 40 a set of resources designed to help people understand fair comparisons of treatments. An important aim of CARL is to promote evaluation of these critical thinking resources and interventions, some of which are currently under way at the Education Endowment Foundation. On 22 May 2017, the foundation is also cohosting an event with the Royal College of Paediatrics and Child Health that will focus on their shared interest in critical thinking and appraisal skills.

Education and healthcare have overlapping interests. Doctors, teachers, researchers, patients, learners, and the public can all benefit from working together to help people to think critically about the choices they make. Events such as the global evidence summit in September 2017 ( https://globalevidencesummit.org ) can help bring people together and build on current international experience.

Contributors and sources: This article reflects conclusions from discussions during 2016 among education and health service researchers exploring opportunities for cross sector collaboration and learning. This group includes people with a longstanding interest in evidence informed policy and practice, with expertise in evaluation design, reviewing methodology, knowledge mobilisation, and critical thinking and appraisal.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

Provenance and peer review: Not commissioned; externally peer reviewed.

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Defining Critical Thinking

1 Introduction to Critical Thinking

I. what is c ritical t hinking [1].

Critical thinking is the ability to think clearly and rationally about what to do or what to believe.  It includes the ability to engage in reflective and independent thinking. Someone with critical thinking skills is able to do the following:

• Understand the logical connections between ideas.
• Identify, construct, and evaluate arguments.
• Detect inconsistencies and common mistakes in reasoning.
• Solve problems systematically.
• Identify the relevance and importance of ideas.
• Reflect on the justification of one’s own beliefs and values.

Critical thinking is not simply a matter of accumulating information. A person with a good memory and who knows a lot of facts is not necessarily good at critical thinking. Critical thinkers are able to deduce consequences from what they know, make use of information to solve problems, and to seek relevant sources of information to inform themselves.

Critical thinking should not be confused with being argumentative or being critical of other people. Although critical thinking skills can be used in exposing fallacies and bad reasoning, critical thinking can also play an important role in cooperative reasoning and constructive tasks. Critical thinking can help us acquire knowledge, improve our theories, and strengthen arguments. We can also use critical thinking to enhance work processes and improve social institutions.

Some people believe that critical thinking hinders creativity because critical thinking requires following the rules of logic and rationality, whereas creativity might require breaking those rules. This is a misconception. Critical thinking is quite compatible with thinking “out-of-the-box,” challenging consensus views, and pursuing less popular approaches. If anything, critical thinking is an essential part of creativity because we need critical thinking to evaluate and improve our creative ideas.

II. The I mportance of C ritical T hinking

Critical thinking is a domain-general thinking skill. The ability to think clearly and rationally is important whatever we choose to do. If you work in education, research, finance, management or the legal profession, then critical thinking is obviously important. But critical thinking skills are not restricted to a particular subject area. Being able to think well and solve problems systematically is an asset for any career.

Critical thinking is very important in the new knowledge economy.  The global knowledge economy is driven by information and technology. One has to be able to deal with changes quickly and effectively. The new economy places increasing demands on flexible intellectual skills, and the ability to analyze information and integrate diverse sources of knowledge in solving problems. Good critical thinking promotes such thinking skills, and is very important in the fast-changing workplace.

Critical thinking enhances language and presentation skills. Thinking clearly and systematically can improve the way we express our ideas. In learning how to analyze the logical structure of texts, critical thinking also improves comprehension abilities.

Critical thinking promotes creativity. To come up with a creative solution to a problem involves not just having new ideas. It must also be the case that the new ideas being generated are useful and relevant to the task at hand. Critical thinking plays a crucial role in evaluating new ideas, selecting the best ones and modifying them if necessary.

Critical thinking is crucial for self-reflection. In order to live a meaningful life and to structure our lives accordingly, we need to justify and reflect on our values and decisions. Critical thinking provides the tools for this process of self-evaluation.

Good critical thinking is the foundation of science and democracy. Science requires the critical use of reason in experimentation and theory confirmation. The proper functioning of a liberal democracy requires citizens who can think critically about social issues to inform their judgments about proper governance and to overcome biases and prejudice.

Critical thinking is a   metacognitive skill . What this means is that it is a higher-level cognitive skill that involves thinking about thinking. We have to be aware of the good principles of reasoning, and be reflective about our own reasoning. In addition, we often need to make a conscious effort to improve ourselves, avoid biases, and maintain objectivity. This is notoriously hard to do. We are all able to think but to think well often requires a long period of training. The mastery of critical thinking is similar to the mastery of many other skills. There are three important components: theory, practice, and attitude.

III. Improv ing O ur T hinking S kills

If we want to think correctly, we need to follow the correct rules of reasoning. Knowledge of theory includes knowledge of these rules. These are the basic principles of critical thinking, such as the laws of logic, and the methods of scientific reasoning, etc.

Also, it would be useful to know something about what not to do if we want to reason correctly. This means we should have some basic knowledge of the mistakes that people make. First, this requires some knowledge of typical fallacies. Second, psychologists have discovered persistent biases and limitations in human reasoning. An awareness of these empirical findings will alert us to potential problems.

However, merely knowing the principles that distinguish good and bad reasoning is not enough. We might study in the classroom about how to swim, and learn about the basic theory, such as the fact that one should not breathe underwater. But unless we can apply such theoretical knowledge through constant practice, we might not actually be able to swim.

Similarly, to be good at critical thinking skills it is necessary to internalize the theoretical principles so that we can actually apply them in daily life. There are at least two ways to do this. One is to perform lots of quality exercises. These exercises don’t just include practicing in the classroom or receiving tutorials; they also include engaging in discussions and debates with other people in our daily lives, where the principles of critical thinking can be applied. The second method is to think more deeply about the principles that we have acquired. In the human mind, memory and understanding are acquired through making connections between ideas.

Good critical thinking skills require more than just knowledge and practice. Persistent practice can bring about improvements only if one has the right kind of motivation and attitude. The following attitudes are not uncommon, but they are obstacles to critical thinking:

• I prefer being given the correct answers rather than figuring them out myself.
• I don’t like to think a lot about my decisions as I rely only on gut feelings.
• I don’t usually review the mistakes I have made.
• I don’t like to be criticized.

To improve our thinking we have to recognize the importance of reflecting on the reasons for belief and action. We should also be willing to engage in debate, break old habits, and deal with linguistic complexities and abstract concepts.

The  California Critical Thinking Disposition Inventory  is a psychological test that is used to measure whether people are disposed to think critically. It measures the seven different thinking habits listed below, and it is useful to ask ourselves to what extent they describe the way we think:

• Truth-Seeking—Do you try to understand how things really are? Are you interested in finding out the truth?
• Open-Mindedness—How receptive are you to new ideas, even when you do not intuitively agree with them? Do you give new concepts a fair hearing?
• Analyticity—Do you try to understand the reasons behind things? Do you act impulsively or do you evaluate the pros and cons of your decisions?
• Systematicity—Are you systematic in your thinking? Do you break down a complex problem into parts?
• Confidence in Reasoning—Do you always defer to other people? How confident are you in your own judgment? Do you have reasons for your confidence? Do you have a way to evaluate your own thinking?
• Inquisitiveness—Are you curious about unfamiliar topics and resolving complicated problems? Will you chase down an answer until you find it?
• Maturity of Judgment—Do you jump to conclusions? Do you try to see things from different perspectives? Do you take other people’s experiences into account?

Finally, as mentioned earlier, psychologists have discovered over the years that human reasoning can be easily affected by a variety of cognitive biases. For example, people tend to be over-confident of their abilities and focus too much on evidence that supports their pre-existing opinions. We should be alert to these biases in our attitudes towards our own thinking.

IV. Defining Critical Thinking

There are many different definitions of critical thinking. Here we list some of the well-known ones. You might notice that they all emphasize the importance of clarity and rationality. Here we will look at some well-known definitions in chronological order.

1) Many people trace the importance of critical thinking in education to the early twentieth-century American philosopher John Dewey. But Dewey did not make very extensive use of the term “critical thinking.” Instead, in his book  How We Think (1910), he argued for the importance of what he called “reflective thinking”:

…[when] the ground or basis for a belief is deliberately sought and its adequacy to support the belief examined. This process is called reflective thought; it alone is truly educative in value…

Active, persistent and careful consideration of any belief or supposed form of knowledge in light of the grounds that support it, and the further conclusions to which it tends, constitutes reflective thought.

There is however one passage from How We Think where Dewey explicitly uses the term “critical thinking”:

The essence of critical thinking is suspended judgment; and the essence of this suspense is inquiry to determine the nature of the problem before proceeding to attempts at its solution. This, more than any other thing, transforms mere inference into tested inference, suggested conclusions into proof.

2) The  Watson-Glaser Critical Thinking Appraisal  (1980) is a well-known psychological test of critical thinking ability. The authors of this test define critical thinking as:

…a composite of attitudes, knowledge and skills. This composite includes: (1) attitudes of inquiry that involve an ability to recognize the existence of problems and an acceptance of the general need for evidence in support of what is asserted to be true; (2) knowledge of the nature of valid inferences, abstractions, and generalizations in which the weight or accuracy of different kinds of evidence are logically determined; and (3) skills in employing and applying the above attitudes and knowledge.

3) A very well-known and influential definition of critical thinking comes from philosopher and professor Robert Ennis in his work “A Taxonomy of Critical Thinking Dispositions and Abilities” (1987):

Critical thinking is reasonable reflective thinking that is focused on deciding what to believe or do.

4) The following definition comes from a statement written in 1987 by the philosophers Michael Scriven and Richard Paul for the  National Council for Excellence in Critical Thinking (link), an organization promoting critical thinking in the US:

Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness. It entails the examination of those structures or elements of thought implicit in all reasoning: purpose, problem, or question-at-issue, assumptions, concepts, empirical grounding; reasoning leading to conclusions, implications and consequences, objections from alternative viewpoints, and frame of reference.

The following excerpt from Peter A. Facione’s “Critical Thinking: A Statement of Expert Consensus for Purposes of Educational Assessment and Instruction” (1990) is quoted from a report written for the American Philosophical Association:

We understand critical thinking to be purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based. CT is essential as a tool of inquiry. As such, CT is a liberating force in education and a powerful resource in one’s personal and civic life. While not synonymous with good thinking, CT is a pervasive and self-rectifying human phenomenon. The ideal critical thinker is habitually inquisitive, well-informed, trustful of reason, open-minded, flexible, fairminded in evaluation, honest in facing personal biases, prudent in making judgments, willing to reconsider, clear about issues, orderly in complex matters, diligent in seeking relevant information, reasonable in the selection of criteria, focused in inquiry, and persistent in seeking results which are as precise as the subject and the circumstances of inquiry permit. Thus, educating good critical thinkers means working toward this ideal. It combines developing CT skills with nurturing those dispositions which consistently yield useful insights and which are the basis of a rational and democratic society.

V. Two F eatures of C ritical T hinking

A. how not what .

Critical thinking is concerned not with what you believe, but rather how or why you believe it. Most classes, such as those on biology or chemistry, teach you what to believe about a subject matter. In contrast, critical thinking is not particularly interested in what the world is, in fact, like. Rather, critical thinking will teach you how to form beliefs and how to think. It is interested in the type of reasoning you use when you form your beliefs, and concerns itself with whether you have good reasons to believe what you believe. Therefore, this class isn’t a class on the psychology of reasoning, which brings us to the second important feature of critical thinking.

B. Ought N ot Is ( or Normative N ot Descriptive )

There is a difference between normative and descriptive theories. Descriptive theories, such as those provided by physics, provide a picture of how the world factually behaves and operates. In contrast, normative theories, such as those provided by ethics or political philosophy, provide a picture of how the world should be. Rather than ask question such as why something is the way it is, normative theories ask how something should be. In this course, we will be interested in normative theories that govern our thinking and reasoning. Therefore, we will not be interested in how we actually reason, but rather focus on how we ought to reason.

In the introduction to this course we considered a selection task with cards that must be flipped in order to check the validity of a rule. We noted that many people fail to identify all the cards required to check the rule. This is how people do in fact reason (descriptive). We then noted that you must flip over two cards. This is how people ought to reason (normative).

• Section I-IV are taken from http://philosophy.hku.hk/think/ and are in use under the creative commons license. Some modifications have been made to the original content. ↵

Critical Thinking Copyright © 2019 by Brian Kim is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Critical thinking and evidence-based practice

Affiliation.

• 1 Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada. [email protected]
• PMID: 16311232
• DOI: 10.1016/j.profnurs.2005.10.002

Critical thinking (CT) is vital to evidence-based nursing practice. Evidence-based practice (EBP) supports nursing care and can contribute positively to patient outcomes across a variety of settings and geographic locations. The nature of EBP, its relevance to nursing, and the skills needed to support it should be required components of baccalaureate education and must be introduced early in students' development as independent, self-directed learners and as professional nurses. Among the knowledge, skills, and processes needed to support EBP, CT is paramount. The development of CT can prepare nurses with the necessary skills and dispositions (habits of mind, attitudes, and traits) to support EBP. The intents of this study were to explore the importance of CT as an essential skill to support EBP and to describe some of the strategies and processes considered key to the ongoing development of CT.

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• Nurses / psychology
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• Nursing Research* / education
• Nursing Research* / organization & administration
• Organizational Innovation
• Philosophy, Nursing
• Problem-Based Learning
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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 6 clinical reasoning, decisionmaking, and action: thinking critically and clinically.

Patricia Benner ; Ronda G. Hughes ; Molly Sutphen .

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This chapter examines multiple thinking strategies that are needed for high-quality clinical practice. Clinical reasoning and judgment are examined in relation to other modes of thinking used by clinical nurses in providing quality health care to patients that avoids adverse events and patient harm. The clinician’s ability to provide safe, high-quality care can be dependent upon their ability to reason, think, and judge, which can be limited by lack of experience. The expert performance of nurses is dependent upon continual learning and evaluation of performance.

• Critical Thinking

Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years. 1 The definitions of critical thinking have evolved over the years. There are several key definitions for critical thinking to consider. The American Philosophical Association (APA) defined critical thinking as purposeful, self-regulatory judgment that uses cognitive tools such as interpretation, analysis, evaluation, inference, and explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations on which judgment is based. 2 A more expansive general definition of critical thinking is

. . . in short, self-directed, self-disciplined, self-monitored, and self-corrective thinking. It presupposes assent to rigorous standards of excellence and mindful command of their use. It entails effective communication and problem solving abilities and a commitment to overcome our native egocentrism and sociocentrism. Every clinician must develop rigorous habits of critical thinking, but they cannot escape completely the situatedness and structures of the clinical traditions and practices in which they must make decisions and act quickly in specific clinical situations. 3

There are three key definitions for nursing, which differ slightly. Bittner and Tobin defined critical thinking as being “influenced by knowledge and experience, using strategies such as reflective thinking as a part of learning to identify the issues and opportunities, and holistically synthesize the information in nursing practice” 4 (p. 268). Scheffer and Rubenfeld 5 expanded on the APA definition for nurses through a consensus process, resulting in the following definition:

Critical thinking in nursing is an essential component of professional accountability and quality nursing care. Critical thinkers in nursing exhibit these habits of the mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, openmindedness, perseverance, and reflection. Critical thinkers in nursing practice the cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge 6 (Scheffer & Rubenfeld, p. 357).

The National League for Nursing Accreditation Commission (NLNAC) defined critical thinking as:

the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factually and belief based. This is demonstrated in nursing by clinical judgment, which includes ethical, diagnostic, and therapeutic dimensions and research 7 (p. 8).

These concepts are furthered by the American Association of Colleges of Nurses’ definition of critical thinking in their Essentials of Baccalaureate Nursing :

Critical thinking underlies independent and interdependent decision making. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity 8 (p. 9).

Course work or ethical experiences should provide the graduate with the knowledge and skills to:

• Use nursing and other appropriate theories and models, and an appropriate ethical framework;
• Apply research-based knowledge from nursing and the sciences as the basis for practice;
• Use clinical judgment and decision-making skills;
• Engage in self-reflective and collegial dialogue about professional practice;
• Evaluate nursing care outcomes through the acquisition of data and the questioning of inconsistencies, allowing for the revision of actions and goals;
• Engage in creative problem solving 8 (p. 10).

Taken together, these definitions of critical thinking set forth the scope and key elements of thought processes involved in providing clinical care. Exactly how critical thinking is defined will influence how it is taught and to what standard of care nurses will be held accountable.

Professional and regulatory bodies in nursing education have required that critical thinking be central to all nursing curricula, but they have not adequately distinguished critical reflection from ethical, clinical, or even creative thinking for decisionmaking or actions required by the clinician. Other essential modes of thought such as clinical reasoning, evaluation of evidence, creative thinking, or the application of well-established standards of practice—all distinct from critical reflection—have been subsumed under the rubric of critical thinking. In the nursing education literature, clinical reasoning and judgment are often conflated with critical thinking. The accrediting bodies and nursing scholars have included decisionmaking and action-oriented, practical, ethical, and clinical reasoning in the rubric of critical reflection and thinking. One might say that this harmless semantic confusion is corrected by actual practices, except that students need to understand the distinctions between critical reflection and clinical reasoning, and they need to learn to discern when each is better suited, just as students need to also engage in applying standards, evidence-based practices, and creative thinking.

The growing body of research, patient acuity, and complexity of care demand higher-order thinking skills. Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. These skills can be cultivated by educators who display the virtues of critical thinking, including independence of thought, intellectual curiosity, courage, humility, empathy, integrity, perseverance, and fair-mindedness. 9

The process of critical thinking is stimulated by integrating the essential knowledge, experiences, and clinical reasoning that support professional practice. The emerging paradigm for clinical thinking and cognition is that it is social and dialogical rather than monological and individual. 10–12 Clinicians pool their wisdom and multiple perspectives, yet some clinical knowledge can be demonstrated only in the situation (e.g., how to suction an extremely fragile patient whose oxygen saturations sink too low). Early warnings of problematic situations are made possible by clinicians comparing their observations to that of other providers. Clinicians form practice communities that create styles of practice, including ways of doing things, communication styles and mechanisms, and shared expectations about performance and expertise of team members.

By holding up critical thinking as a large umbrella for different modes of thinking, students can easily misconstrue the logic and purposes of different modes of thinking. Clinicians and scientists alike need multiple thinking strategies, such as critical thinking, clinical judgment, diagnostic reasoning, deliberative rationality, scientific reasoning, dialogue, argument, creative thinking, and so on. In particular, clinicians need forethought and an ongoing grasp of a patient’s health status and care needs trajectory, which requires an assessment of their own clarity and understanding of the situation at hand, critical reflection, critical reasoning, and clinical judgment.

Critical Reflection, Critical Reasoning, and Judgment

Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury. For example, in everyday practice, clinicians cannot afford to critically reflect on the well-established tenets of “normal” or “typical” human circulatory systems when trying to figure out a particular patient’s alterations from that typical, well-grounded understanding that has existed since Harvey’s work in 1628. 13 Yet critical reflection can generate new scientifically based ideas. For example, there is a lack of adequate research on the differences between women’s and men’s circulatory systems and the typical pathophysiology related to heart attacks. Available research is based upon multiple, taken-for-granted starting points about the general nature of the circulatory system. As such, critical reflection may not provide what is needed for a clinician to act in a situation. This idea can be considered reasonable since critical reflective thinking is not sufficient for good clinical reasoning and judgment. The clinician’s development of skillful critical reflection depends upon being taught what to pay attention to, and thus gaining a sense of salience that informs the powers of perceptual grasp. The powers of noticing or perceptual grasp depend upon noticing what is salient and the capacity to respond to the situation.

Critical reflection is a crucial professional skill, but it is not the only reasoning skill or logic clinicians require. The ability to think critically uses reflection, induction, deduction, analysis, challenging assumptions, and evaluation of data and information to guide decisionmaking. 9 , 14 , 15 Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals, 16 while considering the patient’s situation. 14 It is a process where both inductive and deductive cognitive skills are used. 17 Sometimes clinical reasoning is presented as a form of evaluating scientific knowledge, sometimes even as a form of scientific reasoning. Critical thinking is inherent in making sound clinical reasoning. 18

An essential point of tension and confusion exists in practice traditions such as nursing and medicine when clinical reasoning and critical reflection become entangled, because the clinician must have some established bases that are not questioned when engaging in clinical decisions and actions, such as standing orders. The clinician must act in the particular situation and time with the best clinical and scientific knowledge available. The clinician cannot afford to indulge in either ritualistic unexamined knowledge or diagnostic or therapeutic nihilism caused by radical doubt, as in critical reflection, because they must find an intelligent and effective way to think and act in particular clinical situations. Critical reflection skills are essential to assist practitioners to rethink outmoded or even wrong-headed approaches to health care, health promotion, and prevention of illness and complications, especially when new evidence is available. Breakdowns in practice, high failure rates in particular therapies, new diseases, new scientific discoveries, and societal changes call for critical reflection about past assumptions and no-longer-tenable beliefs.

Clinical reasoning stands out as a situated, practice-based form of reasoning that requires a background of scientific and technological research-based knowledge about general cases, more so than any particular instance. It also requires practical ability to discern the relevance of the evidence behind general scientific and technical knowledge and how it applies to a particular patient. In dong so, the clinician considers the patient’s particular clinical trajectory, their concerns and preferences, and their particular vulnerabilities (e.g., having multiple comorbidities) and sensitivities to care interventions (e.g., known drug allergies, other conflicting comorbid conditions, incompatible therapies, and past responses to therapies) when forming clinical decisions or conclusions.

Situated in a practice setting, clinical reasoning occurs within social relationships or situations involving patient, family, community, and a team of health care providers. The expert clinician situates themselves within a nexus of relationships, with concerns that are bounded by the situation. Expert clinical reasoning is socially engaged with the relationships and concerns of those who are affected by the caregiving situation, and when certain circumstances are present, the adverse event. Halpern 19 has called excellent clinical ethical reasoning “emotional reasoning” in that the clinicians have emotional access to the patient/family concerns and their understanding of the particular care needs. Expert clinicians also seek an optimal perceptual grasp, one based on understanding and as undistorted as possible, based on an attuned emotional engagement and expert clinical knowledge. 19 , 20

Clergy educators 21 and nursing and medical educators have begun to recognize the wisdom of broadening their narrow vision of rationality beyond simple rational calculation (exemplified by cost-benefit analysis) to reconsider the need for character development—including emotional engagement, perception, habits of thought, and skill acquisition—as essential to the development of expert clinical reasoning, judgment, and action. 10 , 22–24 Practitioners of engineering, law, medicine, and nursing, like the clergy, have to develop a place to stand in their discipline’s tradition of knowledge and science in order to recognize and evaluate salient evidence in the moment. Diagnostic confusion and disciplinary nihilism are both threats to the clinician’s ability to act in particular situations. However, the practice and practitioners will not be self-improving and vital if they cannot engage in critical reflection on what is not of value, what is outmoded, and what does not work. As evidence evolves and expands, so too must clinical thought.

Clinical judgment requires clinical reasoning across time about the particular, and because of the relevance of this immediate historical unfolding, clinical reasoning can be very different from the scientific reasoning used to formulate, conduct, and assess clinical experiments. While scientific reasoning is also socially embedded in a nexus of social relationships and concerns, the goal of detached, critical objectivity used to conduct scientific experiments minimizes the interactive influence of the research on the experiment once it has begun. Scientific research in the natural and clinical sciences typically uses formal criteria to develop “yes” and “no” judgments at prespecified times. The scientist is always situated in past and immediate scientific history, preferring to evaluate static and predetermined points in time (e.g., snapshot reasoning), in contrast to a clinician who must always reason about transitions over time. 25 , 26

Techne and Phronesis

Distinctions between the mere scientific making of things and practice was first explored by Aristotle as distinctions between techne and phronesis. 27 Learning to be a good practitioner requires developing the requisite moral imagination for good practice. If, for example, patients exercise their rights and refuse treatments, practitioners are required to have the moral imagination to understand the probable basis for the patient’s refusal. For example, was the refusal based upon catastrophic thinking, unrealistic fears, misunderstanding, or even clinical depression?

Techne, as defined by Aristotle, encompasses the notion of formation of character and habitus 28 as embodied beings. In Aristotle’s terms, techne refers to the making of things or producing outcomes. 11 Joseph Dunne defines techne as “the activity of producing outcomes,” and it “is governed by a means-ends rationality where the maker or producer governs the thing or outcomes produced or made through gaining mastery over the means of producing the outcomes, to the point of being able to separate means and ends” 11 (p. 54). While some aspects of medical and nursing practice fall into the category of techne, much of nursing and medical practice falls outside means-ends rationality and must be governed by concern for doing good or what is best for the patient in particular circumstances, where being in a relationship and discerning particular human concerns at stake guide action.

Phronesis, in contrast to techne, includes reasoning about the particular, across time, through changes or transitions in the patient’s and/or the clinician’s understanding. As noted by Dunne, phronesis is “characterized at least as much by a perceptiveness with regard to concrete particulars as by a knowledge of universal principles” 11 (p. 273). This type of practical reasoning often takes the form of puzzle solving or the evaluation of immediate past “hot” history of the patient’s situation. Such a particular clinical situation is necessarily particular, even though many commonalities and similarities with other disease syndromes can be recognized through signs and symptoms and laboratory tests. 11 , 29 , 30 Pointing to knowledge embedded in a practice makes no claim for infallibility or “correctness.” Individual practitioners can be mistaken in their judgments because practices such as medicine and nursing are inherently underdetermined. 31

While phronetic knowledge must remain open to correction and improvement, real events, and consequences, it cannot consistently transcend the institutional setting’s capacities and supports for good practice. Phronesis is also dependent on ongoing experiential learning of the practitioner, where knowledge is refined, corrected, or refuted. The Western tradition, with the notable exception of Aristotle, valued knowledge that could be made universal and devalued practical know-how and experiential learning. Descartes codified this preference for formal logic and rational calculation.

Aristotle recognized that when knowledge is underdetermined, changeable, and particular, it cannot be turned into the universal or standardized. It must be perceived, discerned, and judged, all of which require experiential learning. In nursing and medicine, perceptual acuity in physical assessment and clinical judgment (i.e., reasoning across time about changes in the particular patient or the clinician’s understanding of the patient’s condition) fall into the Greek Aristotelian category of phronesis. Dewey 32 sought to rescue knowledge gained by practical activity in the world. He identified three flaws in the understanding of experience in Greek philosophy: (1) empirical knowing is the opposite of experience with science; (2) practice is reduced to techne or the application of rational thought or technique; and (3) action and skilled know-how are considered temporary and capricious as compared to reason, which the Greeks considered as ultimate reality.

In practice, nursing and medicine require both techne and phronesis. The clinician standardizes and routinizes what can be standardized and routinized, as exemplified by standardized blood pressure measurements, diagnoses, and even charting about the patient’s condition and treatment. 27 Procedural and scientific knowledge can often be formalized and standardized (e.g., practice guidelines), or at least made explicit and certain in practice, except for the necessary timing and adjustments made for particular patients. 11 , 22

Rational calculations available to techne—population trends and statistics, algorithms—are created as decision support structures and can improve accuracy when used as a stance of inquiry in making clinical judgments about particular patients. Aggregated evidence from clinical trials and ongoing working knowledge of pathophysiology, biochemistry, and genomics are essential. In addition, the skills of phronesis (clinical judgment that reasons across time, taking into account the transitions of the particular patient/family/community and transitions in the clinician’s understanding of the clinical situation) will be required for nursing, medicine, or any helping profession.

Thinking Critically

Being able to think critically enables nurses to meet the needs of patients within their context and considering their preferences; meet the needs of patients within the context of uncertainty; consider alternatives, resulting in higher-quality care; 33 and think reflectively, rather than simply accepting statements and performing tasks without significant understanding and evaluation. 34 Skillful practitioners can think critically because they have the following cognitive skills: information seeking, discriminating, analyzing, transforming knowledge, predicating, applying standards, and logical reasoning. 5 One’s ability to think critically can be affected by age, length of education (e.g., an associate vs. a baccalaureate decree in nursing), and completion of philosophy or logic subjects. 35–37 The skillful practitioner can think critically because of having the following characteristics: motivation, perseverance, fair-mindedness, and deliberate and careful attention to thinking. 5 , 9

Thinking critically implies that one has a knowledge base from which to reason and the ability to analyze and evaluate evidence. 38 Knowledge can be manifest by the logic and rational implications of decisionmaking. Clinical decisionmaking is particularly influenced by interpersonal relationships with colleagues, 39 patient conditions, availability of resources, 40 knowledge, and experience. 41 Of these, experience has been shown to enhance nurses’ abilities to make quick decisions 42 and fewer decision errors, 43 support the identification of salient cues, and foster the recognition and action on patterns of information. 44 , 45

Clinicians must develop the character and relational skills that enable them to perceive and understand their patient’s needs and concerns. This requires accurate interpretation of patient data that is relevant to the specific patient and situation. In nursing, this formation of moral agency focuses on learning to be responsible in particular ways demanded by the practice, and to pay attention and intelligently discern changes in patients’ concerns and/or clinical condition that require action on the part of the nurse or other health care workers to avert potential compromises to quality care.

Formation of the clinician’s character, skills, and habits are developed in schools and particular practice communities within a larger practice tradition. As Dunne notes,

A practice is not just a surface on which one can display instant virtuosity. It grounds one in a tradition that has been formed through an elaborate development and that exists at any juncture only in the dispositions (slowly and perhaps painfully acquired) of its recognized practitioners. The question may of course be asked whether there are any such practices in the contemporary world, whether the wholesale encroachment of Technique has not obliterated them—and whether this is not the whole point of MacIntyre’s recipe of withdrawal, as well as of the post-modern story of dispossession 11 (p. 378).

Clearly Dunne is engaging in critical reflection about the conditions for developing character, skills, and habits for skillful and ethical comportment of practitioners, as well as to act as moral agents for patients so that they and their families receive safe, effective, and compassionate care.

Professional socialization or professional values, while necessary, do not adequately address character and skill formation that transform the way the practitioner exists in his or her world, what the practitioner is capable of noticing and responding to, based upon well-established patterns of emotional responses, skills, dispositions to act, and the skills to respond, decide, and act. 46 The need for character and skill formation of the clinician is what makes a practice stand out from a mere technical, repetitious manufacturing process. 11 , 30 , 47

In nursing and medicine, many have questioned whether current health care institutions are designed to promote or hinder enlightened, compassionate practice, or whether they have deteriorated into commercial institutional models that focus primarily on efficiency and profit. MacIntyre points out the links between the ongoing development and improvement of practice traditions and the institutions that house them:

Lack of justice, lack of truthfulness, lack of courage, lack of the relevant intellectual virtues—these corrupt traditions, just as they do those institutions and practices which derive their life from the traditions of which they are the contemporary embodiments. To recognize this is of course also to recognize the existence of an additional virtue, one whose importance is perhaps most obvious when it is least present, the virtue of having an adequate sense of the traditions to which one belongs or which confront one. This virtue is not to be confused with any form of conservative antiquarianism; I am not praising those who choose the conventional conservative role of laudator temporis acti. It is rather the case that an adequate sense of tradition manifests itself in a grasp of those future possibilities which the past has made available to the present. Living traditions, just because they continue a not-yet-completed narrative, confront a future whose determinate and determinable character, so far as it possesses any, derives from the past 30 (p. 207).

It would be impossible to capture all the situated and distributed knowledge outside of actual practice situations and particular patients. Simulations are powerful as teaching tools to enable nurses’ ability to think critically because they give students the opportunity to practice in a simplified environment. However, students can be limited in their inability to convey underdetermined situations where much of the information is based on perceptions of many aspects of the patient and changes that have occurred over time. Simulations cannot have the sub-cultures formed in practice settings that set the social mood of trust, distrust, competency, limited resources, or other forms of situated possibilities.

One of the hallmark studies in nursing providing keen insight into understanding the influence of experience was a qualitative study of adult, pediatric, and neonatal intensive care unit (ICU) nurses, where the nurses were clustered into advanced beginner, intermediate, and expert level of practice categories. The advanced beginner (having up to 6 months of work experience) used procedures and protocols to determine which clinical actions were needed. When confronted with a complex patient situation, the advanced beginner felt their practice was unsafe because of a knowledge deficit or because of a knowledge application confusion. The transition from advanced beginners to competent practitioners began when they first had experience with actual clinical situations and could benefit from the knowledge gained from the mistakes of their colleagues. Competent nurses continuously questioned what they saw and heard, feeling an obligation to know more about clinical situations. In doing do, they moved from only using care plans and following the physicians’ orders to analyzing and interpreting patient situations. Beyond that, the proficient nurse acknowledged the changing relevance of clinical situations requiring action beyond what was planned or anticipated. The proficient nurse learned to acknowledge the changing needs of patient care and situation, and could organize interventions “by the situation as it unfolds rather than by preset goals 48 (p. 24). Both competent and proficient nurses (that is, intermediate level of practice) had at least two years of ICU experience. 48 Finally, the expert nurse had a more fully developed grasp of a clinical situation, a sense of confidence in what is known about the situation, and could differentiate the precise clinical problem in little time. 48

Expertise is acquired through professional experience and is indicative of a nurse who has moved beyond mere proficiency. As Gadamer 29 points out, experience involves a turning around of preconceived notions, preunderstandings, and extends or adds nuances to understanding. Dewey 49 notes that experience requires a prepared “creature” and an enriched environment. The opportunity to reflect and narrate one’s experiential learning can clarify, extend, or even refute experiential learning.

Experiential learning requires time and nurturing, but time alone does not ensure experiential learning. Aristotle linked experiential learning to the development of character and moral sensitivities of a person learning a practice. 50 New nurses/new graduates have limited work experience and must experience continuing learning until they have reached an acceptable level of performance. 51 After that, further improvements are not predictable, and years of experience are an inadequate predictor of expertise. 52

The most effective knower and developer of practical knowledge creates an ongoing dialogue and connection between lessons of the day and experiential learning over time. Gadamer, in a late life interview, highlighted the open-endedness and ongoing nature of experiential learning in the following interview response:

Being experienced does not mean that one now knows something once and for all and becomes rigid in this knowledge; rather, one becomes more open to new experiences. A person who is experienced is undogmatic. Experience has the effect of freeing one to be open to new experience … In our experience we bring nothing to a close; we are constantly learning new things from our experience … this I call the interminability of all experience 32 (p. 403).

Practical endeavor, supported by scientific knowledge, requires experiential learning, the development of skilled know-how, and perceptual acuity in order to make the scientific knowledge relevant to the situation. Clinical perceptual and skilled know-how helps the practitioner discern when particular scientific findings might be relevant. 53

Often experience and knowledge, confirmed by experimentation, are treated as oppositions, an either-or choice. However, in practice it is readily acknowledged that experiential knowledge fuels scientific investigation, and scientific investigation fuels further experiential learning. Experiential learning from particular clinical cases can help the clinician recognize future similar cases and fuel new scientific questions and study. For example, less experienced nurses—and it could be argued experienced as well—can use nursing diagnoses practice guidelines as part of their professional advancement. Guidelines are used to reflect their interpretation of patients’ needs, responses, and situation, 54 a process that requires critical thinking and decisionmaking. 55 , 56 Using guidelines also reflects one’s problem identification and problem-solving abilities. 56 Conversely, the ability to proficiently conduct a series of tasks without nursing diagnoses is the hallmark of expertise. 39 , 57

Experience precedes expertise. As expertise develops from experience and gaining knowledge and transitions to the proficiency stage, the nurses’ thinking moves from steps and procedures (i.e., task-oriented care) toward “chunks” or patterns 39 (i.e., patient-specific care). In doing so, the nurse thinks reflectively, rather than merely accepting statements and performing procedures without significant understanding and evaluation. 34 Expert nurses do not rely on rules and logical thought processes in problem-solving and decisionmaking. 39 Instead, they use abstract principles, can see the situation as a complex whole, perceive situations comprehensively, and can be fully involved in the situation. 48 Expert nurses can perform high-level care without conscious awareness of the knowledge they are using, 39 , 58 and they are able to provide that care with flexibility and speed. Through a combination of knowledge and skills gained from a range of theoretical and experiential sources, expert nurses also provide holistic care. 39 Thus, the best care comes from the combination of theoretical, tacit, and experiential knowledge. 59 , 60

Experts are thought to eventually develop the ability to intuitively know what to do and to quickly recognize critical aspects of the situation. 22 Some have proposed that expert nurses provide high-quality patient care, 61 , 62 but that is not consistently documented—particularly in consideration of patient outcomes—and a full understanding between the differential impact of care rendered by an “expert” nurse is not fully understood. In fact, several studies have found that length of professional experience is often unrelated and even negatively related to performance measures and outcomes. 63 , 64

In a review of the literature on expertise in nursing, Ericsson and colleagues 65 found that focusing on challenging, less-frequent situations would reveal individual performance differences on tasks that require speed and flexibility, such as that experienced during a code or an adverse event. Superior performance was associated with extensive training and immediate feedback about outcomes, which can be obtained through continual training, simulation, and processes such as root-cause analysis following an adverse event. Therefore, efforts to improve performance benefited from continual monitoring, planning, and retrospective evaluation. Even then, the nurse’s ability to perform as an expert is dependent upon their ability to use intuition or insights gained through interactions with patients. 39

Intuition and Perception

Intuition is the instant understanding of knowledge without evidence of sensible thought. 66 According to Young, 67 intuition in clinical practice is a process whereby the nurse recognizes something about a patient that is difficult to verbalize. Intuition is characterized by factual knowledge, “immediate possession of knowledge, and knowledge independent of the linear reasoning process” 68 (p. 23). When intuition is used, one filters information initially triggered by the imagination, leading to the integration of all knowledge and information to problem solve. 69 Clinicians use their interactions with patients and intuition, drawing on tacit or experiential knowledge, 70 , 71 to apply the correct knowledge to make the correct decisions to address patient needs. Yet there is a “conflated belief in the nurses’ ability to know what is best for the patient” 72 (p. 251) because the nurses’ and patients’ identification of the patients’ needs can vary. 73

A review of research and rhetoric involving intuition by King and Appleton 62 found that all nurses, including students, used intuition (i.e., gut feelings). They found evidence, predominately in critical care units, that intuition was triggered in response to knowledge and as a trigger for action and/or reflection with a direct bearing on the analytical process involved in patient care. The challenge for nurses was that rigid adherence to checklists, guidelines, and standardized documentation, 62 ignored the benefits of intuition. This view was furthered by Rew and Barrow 68 , 74 in their reviews of the literature, where they found that intuition was imperative to complex decisionmaking, 68 difficult to measure and assess in a quantitative manner, and was not linked to physiologic measures. 74

Intuition is a way of explaining professional expertise. 75 Expert nurses rely on their intuitive judgment that has been developed over time. 39 , 76 Intuition is an informal, nonanalytically based, unstructured, deliberate calculation that facilitates problem solving, 77 a process of arriving at salient conclusions based on relatively small amounts of knowledge and/or information. 78 Experts can have rapid insight into a situation by using intuition to recognize patterns and similarities, achieve commonsense understanding, and sense the salient information combined with deliberative rationality. 10 Intuitive recognition of similarities and commonalities between patients are often the first diagnostic clue or early warning, which must then be followed up with critical evaluation of evidence among the competing conditions. This situation calls for intuitive judgment that can distinguish “expert human judgment from the decisions” made by a novice 79 (p. 23).

Shaw 80 equates intuition with direct perception. Direct perception is dependent upon being able to detect complex patterns and relationships that one has learned through experience are important. Recognizing these patterns and relationships generally occurs rapidly and is complex, making it difficult to articulate or describe. Perceptual skills, like those of the expert nurse, are essential to recognizing current and changing clinical conditions. Perception requires attentiveness and the development of a sense of what is salient. Often in nursing and medicine, means and ends are fused, as is the case for a “good enough” birth experience and a peaceful death.

• Applying Practice Evidence

Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes. 81–83 Research-based guidelines are intended to provide guidance for specific areas of health care delivery. 84 The clinician—both the novice and expert—is expected to use the best available evidence for the most efficacious therapies and interventions in particular instances, to ensure the highest-quality care, especially when deviations from the evidence-based norm may heighten risks to patient safety. Otherwise, if nursing and medicine were exact sciences, or consisted only of techne, then a 1:1 relationship could be established between results of aggregated evidence-based research and the best path for all patients.

Evaluating Evidence

Before research should be used in practice, it must be evaluated. There are many complexities and nuances in evaluating the research evidence for clinical practice. Evaluation of research behind evidence-based medicine requires critical thinking and good clinical judgment. Sometimes the research findings are mixed or even conflicting. As such, the validity, reliability, and generalizability of available research are fundamental to evaluating whether evidence can be applied in practice. To do so, clinicians must select the best scientific evidence relevant to particular patients—a complex process that involves intuition to apply the evidence. Critical thinking is required for evaluating the best available scientific evidence for the treatment and care of a particular patient.

Good clinical judgment is required to select the most relevant research evidence. The best clinical judgment, that is, reasoning across time about the particular patient through changes in the patient’s concerns and condition and/or the clinician’s understanding, are also required. This type of judgment requires clinicians to make careful observations and evaluations of the patient over time, as well as know the patient’s concerns and social circumstances. To evolve to this level of judgment, additional education beyond clinical preparation if often required.

Sources of Evidence

Evidence that can be used in clinical practice has different sources and can be derived from research, patient’s preferences, and work-related experience. 85 , 86 Nurses have been found to obtain evidence from experienced colleagues believed to have clinical expertise and research-based knowledge 87 as well as other sources.

For many years now, randomized controlled trials (RCTs) have often been considered the best standard for evaluating clinical practice. Yet, unless the common threats to the validity (e.g., representativeness of the study population) and reliability (e.g., consistency in interventions and responses of study participants) of RCTs are addressed, the meaningfulness and generalizability of the study outcomes are very limited. Relevant patient populations may be excluded, such as women, children, minorities, the elderly, and patients with multiple chronic illnesses. The dropout rate of the trial may confound the results. And it is easier to get positive results published than it is to get negative results published. Thus, RCTs are generalizable (i.e., applicable) only to the population studied—which may not reflect the needs of the patient under the clinicians care. In instances such as these, clinicians need to also consider applied research using prospective or retrospective populations with case control to guide decisionmaking, yet this too requires critical thinking and good clinical judgment.

Another source of available evidence may come from the gold standard of aggregated systematic evaluation of clinical trial outcomes for the therapy and clinical condition in question, be generated by basic and clinical science relevant to the patient’s particular pathophysiology or care need situation, or stem from personal clinical experience. The clinician then takes all of the available evidence and considers the particular patient’s known clinical responses to past therapies, their clinical condition and history, the progression or stages of the patient’s illness and recovery, and available resources.

In clinical practice, the particular is examined in relation to the established generalizations of science. With readily available summaries of scientific evidence (e.g., systematic reviews and practice guidelines) available to nurses and physicians, one might wonder whether deep background understanding is still advantageous. Might it not be expendable, since it is likely to be out of date given the current scientific evidence? But this assumption is a false opposition and false choice because without a deep background understanding, the clinician does not know how to best find and evaluate scientific evidence for the particular case in hand. The clinician’s sense of salience in any given situation depends on past clinical experience and current scientific evidence.

Evidence-Based Practice

The concept of evidence-based practice is dependent upon synthesizing evidence from the variety of sources and applying it appropriately to the care needs of populations and individuals. This implies that evidence-based practice, indicative of expertise in practice, appropriately applies evidence to the specific situations and unique needs of patients. 88 , 89 Unfortunately, even though providing evidence-based care is an essential component of health care quality, it is well known that evidence-based practices are not used consistently.

Conceptually, evidence used in practice advances clinical knowledge, and that knowledge supports independent clinical decisions in the best interest of the patient. 90 , 91 Decisions must prudently consider the factors not necessarily addressed in the guideline, such as the patient’s lifestyle, drug sensitivities and allergies, and comorbidities. Nurses who want to improve the quality and safety of care can do so though improving the consistency of data and information interpretation inherent in evidence-based practice.

Initially, before evidence-based practice can begin, there needs to be an accurate clinical judgment of patient responses and needs. In the course of providing care, with careful consideration of patient safety and quality care, clinicians must give attention to the patient’s condition, their responses to health care interventions, and potential adverse reactions or events that could harm the patient. Nonetheless, there is wide variation in the ability of nurses to accurately interpret patient responses 92 and their risks. 93 Even though variance in interpretation is expected, nurses are obligated to continually improve their skills to ensure that patients receive quality care safely. 94 Patients are vulnerable to the actions and experience of their clinicians, which are inextricably linked to the quality of care patients have access to and subsequently receive.

The judgment of the patient’s condition determines subsequent interventions and patient outcomes. Attaining accurate and consistent interpretations of patient data and information is difficult because each piece can have different meanings, and interpretations are influenced by previous experiences. 95 Nurses use knowledge from clinical experience 96 , 97 and—although infrequently—research. 98–100

Once a problem has been identified, using a process that utilizes critical thinking to recognize the problem, the clinician then searches for and evaluates the research evidence 101 and evaluates potential discrepancies. The process of using evidence in practice involves “a problem-solving approach that incorporates the best available scientific evidence, clinicians’ expertise, and patient’s preferences and values” 102 (p. 28). Yet many nurses do not perceive that they have the education, tools, or resources to use evidence appropriately in practice. 103

Reported barriers to using research in practice have included difficulty in understanding the applicability and the complexity of research findings, failure of researchers to put findings into the clinical context, lack of skills in how to use research in practice, 104 , 105 amount of time required to access information and determine practice implications, 105–107 lack of organizational support to make changes and/or use in practice, 104 , 97 , 105 , 107 and lack of confidence in one’s ability to critically evaluate clinical evidence. 108

When Evidence Is Missing

In many clinical situations, there may be no clear guidelines and few or even no relevant clinical trials to guide decisionmaking. In these cases, the latest basic science about cellular and genomic functioning may be the most relevant science, or by default, guestimation. Consequently, good patient care requires more than a straightforward, unequivocal application of scientific evidence. The clinician must be able to draw on a good understanding of basic sciences, as well as guidelines derived from aggregated data and information from research investigations.

Practical knowledge is shaped by one’s practice discipline and the science and technology relevant to the situation at hand. But scientific, formal, discipline-specific knowledge are not sufficient for good clinical practice, whether the discipline be law, medicine, nursing, teaching, or social work. Practitioners still have to learn how to discern generalizable scientific knowledge, know how to use scientific knowledge in practical situations, discern what scientific evidence/knowledge is relevant, assess how the particular patient’s situation differs from the general scientific understanding, and recognize the complexity of care delivery—a process that is complex, ongoing, and changing, as new evidence can overturn old.

Practice communities like individual practitioners may also be mistaken, as is illustrated by variability in practice styles and practice outcomes across hospitals and regions in the United States. This variability in practice is why practitioners must learn to critically evaluate their practice and continually improve their practice over time. The goal is to create a living self-improving tradition.

Within health care, students, scientists, and practitioners are challenged to learn and use different modes of thinking when they are conflated under one term or rubric, using the best-suited thinking strategies for taking into consideration the purposes and the ends of the reasoning. Learning to be an effective, safe nurse or physician requires not only technical expertise, but also the ability to form helping relationships and engage in practical ethical and clinical reasoning. 50 Good ethical comportment requires that both the clinician and the scientist take into account the notions of good inherent in clinical and scientific practices. The notions of good clinical practice must include the relevant significance and the human concerns involved in decisionmaking in particular situations, centered on clinical grasp and clinical forethought.

The Three Apprenticeships of Professional Education

We have much to learn in comparing the pedagogies of formation across the professions, such as is being done currently by the Carnegie Foundation for the Advancement of Teaching. The Carnegie Foundation’s broad research program on the educational preparation of the profession focuses on three essential apprenticeships:

To capture the full range of crucial dimensions in professional education, we developed the idea of a three-fold apprenticeship: (1) intellectual training to learn the academic knowledge base and the capacity to think in ways important to the profession; (2) a skill-based apprenticeship of practice; and (3) an apprenticeship to the ethical standards, social roles, and responsibilities of the profession, through which the novice is introduced to the meaning of an integrated practice of all dimensions of the profession, grounded in the profession’s fundamental purposes. 109

This framework has allowed the investigators to describe tensions and shortfalls as well as strengths of widespread teaching practices, especially at articulation points among these dimensions of professional training.

Research has demonstrated that these three apprenticeships are taught best when they are integrated so that the intellectual training includes skilled know-how, clinical judgment, and ethical comportment. In the study of nursing, exemplary classroom and clinical teachers were found who do integrate the three apprenticeships in all of their teaching, as exemplified by the following anonymous student’s comments:

With that as well, I enjoyed the class just because I do have clinical experience in my background and I enjoyed it because it took those practical applications and the knowledge from pathophysiology and pharmacology, and all the other classes, and it tied it into the actual aspects of like what is going to happen at work. For example, I work in the emergency room and question: Why am I doing this procedure for this particular patient? Beforehand, when I was just a tech and I wasn’t going to school, I’d be doing it because I was told to be doing it—or I’d be doing CPR because, you know, the doc said, start CPR. I really enjoy the Care and Illness because now I know the process, the pathophysiological process of why I’m doing it and the clinical reasons of why they’re making the decisions, and the prioritization that goes on behind it. I think that’s the biggest point. Clinical experience is good, but not everybody has it. Yet when these students transition from school and clinicals to their job as a nurse, they will understand what’s going on and why.

The three apprenticeships are equally relevant and intertwined. In the Carnegie National Study of Nursing Education and the companion study on medical education as well as in cross-professional comparisons, teaching that gives an integrated access to professional practice is being examined. Once the three apprenticeships are separated, it is difficult to reintegrate them. The investigators are encouraged by teaching strategies that integrate the latest scientific knowledge and relevant clinical evidence with clinical reasoning about particular patients in unfolding rather than static cases, while keeping the patient and family experience and concerns relevant to clinical concerns and reasoning.

Clinical judgment or phronesis is required to evaluate and integrate techne and scientific evidence.

Within nursing, professional practice is wise and effective usually to the extent that the professional creates relational and communication contexts where clients/patients can be open and trusting. Effectiveness depends upon mutual influence between patient and practitioner, student and learner. This is another way in which clinical knowledge is dialogical and socially distributed. The following articulation of practical reasoning in nursing illustrates the social, dialogical nature of clinical reasoning and addresses the centrality of perception and understanding to good clinical reasoning, judgment and intervention.

Clinical Grasp *

Clinical grasp describes clinical inquiry in action. Clinical grasp begins with perception and includes problem identification and clinical judgment across time about the particular transitions of particular patients. Garrett Chan 20 described the clinician’s attempt at finding an “optimal grasp” or vantage point of understanding. Four aspects of clinical grasp, which are described in the following paragraphs, include (1) making qualitative distinctions, (2) engaging in detective work, (3) recognizing changing relevance, and (4) developing clinical knowledge in specific patient populations.

Making Qualitative Distinctions

Qualitative distinctions refer to those distinctions that can be made only in a particular contextual or historical situation. The context and sequence of events are essential for making qualitative distinctions; therefore, the clinician must pay attention to transitions in the situation and judgment. Many qualitative distinctions can be made only by observing differences through touch, sound, or sight, such as the qualities of a wound, skin turgor, color, capillary refill, or the engagement and energy level of the patient. Another example is assessing whether the patient was more fatigued after ambulating to the bathroom or from lack of sleep. Likewise the quality of the clinician’s touch is distinct as in offering reassurance, putting pressure on a bleeding wound, and so on. 110

Engaging in Detective Work, Modus Operandi Thinking, and Clinical Puzzle Solving

Clinical situations are open ended and underdetermined. Modus operandi thinking keeps track of the particular patient, the way the illness unfolds, the meanings of the patient’s responses as they have occurred in the particular time sequence. Modus operandi thinking requires keeping track of what has been tried and what has or has not worked with the patient. In this kind of reasoning-in-transition, gains and losses of understanding are noticed and adjustments in the problem approach are made.

We found that teachers in a medical surgical unit at the University of Washington deliberately teach their students to engage in “detective work.” Students are given the daily clinical assignment of “sleuthing” for undetected drug incompatibilities, questionable drug dosages, and unnoticed signs and symptoms. For example, one student noted that an unusual dosage of a heart medication was being given to a patient who did not have heart disease. The student first asked her teacher about the unusually high dosage. The teacher, in turn, asked the student whether she had asked the nurse or the patient about the dosage. Upon the student’s questioning, the nurse did not know why the patient was receiving the high dosage and assumed the drug was for heart disease. The patient’s staff nurse had not questioned the order. When the student asked the patient, the student found that the medication was being given for tremors and that the patient and the doctor had titrated the dosage for control of the tremors. This deliberate approach to teaching detective work, or modus operandi thinking, has characteristics of “critical reflection,” but stays situated and engaged, ferreting out the immediate history and unfolding of events.

Recognizing Changing Clinical Relevance

The meanings of signs and symptoms are changed by sequencing and history. The patient’s mental status, color, or pain level may continue to deteriorate or get better. The direction, implication, and consequences for the changes alter the relevance of the particular facts in the situation. The changing relevance entailed in a patient transitioning from primarily curative care to primarily palliative care is a dramatic example, where symptoms literally take on new meanings and require new treatments.

Developing Clinical Knowledge in Specific Patient Populations

Extensive experience with a specific patient population or patients with particular injuries or diseases allows the clinician to develop comparisons, distinctions, and nuanced differences within the population. The comparisons between many specific patients create a matrix of comparisons for clinicians, as well as a tacit, background set of expectations that create population- and patient-specific detective work if a patient does not meet the usual, predictable transitions in recovery. What is in the background and foreground of the clinician’s attention shifts as predictable changes in the patient’s condition occurs, such as is seen in recovering from heart surgery or progressing through the predictable stages of labor and delivery. Over time, the clinician develops a deep background understanding that allows for expert diagnostic and interventions skills.

Clinical Forethought

Clinical forethought is intertwined with clinical grasp, but it is much more deliberate and even routinized than clinical grasp. Clinical forethought is a pervasive habit of thought and action in nursing practice, and also in medicine, as clinicians think about disease and recovery trajectories and the implications of these changes for treatment. Clinical forethought plays a role in clinical grasp because it structures the practical logic of clinicians. At least four habits of thought and action are evident in what we are calling clinical forethought: (1) future think, (2) clinical forethought about specific patient populations, (3) anticipation of risks for particular patients, and (4) seeing the unexpected.

Future think

Future think is the broadest category of this logic of practice. Anticipating likely immediate futures helps the clinician make good plans and decisions about preparing the environment so that responding rapidly to changes in the patient is possible. Without a sense of salience about anticipated signs and symptoms and preparing the environment, essential clinical judgments and timely interventions would be impossible in the typically fast pace of acute and intensive patient care. Future think governs the style and content of the nurse’s attentiveness to the patient. Whether in a fast-paced care environment or a slower-paced rehabilitation setting, thinking and acting with anticipated futures guide clinical thinking and judgment. Future think captures the way judgment is suspended in a predictive net of anticipation and preparing oneself and the environment for a range of potential events.

Clinical forethought about specific diagnoses and injuries

This habit of thought and action is so second nature to the experienced nurse that the new or inexperienced nurse may have difficulty finding out about what seems to other colleagues as “obvious” preparation for particular patients and situations. Clinical forethought involves much local specific knowledge about who is a good resource and how to marshal support services and equipment for particular patients.

Examples of preparing for specific patient populations are pervasive, such as anticipating the need for a pacemaker during surgery and having the equipment assembled ready for use to save essential time. Another example includes forecasting an accident victim’s potential injuries, and recognizing that intubation might be needed.

Anticipation of crises, risks, and vulnerabilities for particular patients

This aspect of clinical forethought is central to knowing the particular patient, family, or community. Nurses situate the patient’s problems almost like a topography of possibilities. This vital clinical knowledge needs to be communicated to other caregivers and across care borders. Clinical teaching could be improved by enriching curricula with narrative examples from actual practice, and by helping students recognize commonly occurring clinical situations in the simulation and clinical setting. For example, if a patient is hemodynamically unstable, then managing life-sustaining physiologic functions will be a main orienting goal. If the patient is agitated and uncomfortable, then attending to comfort needs in relation to hemodynamics will be a priority. Providing comfort measures turns out to be a central background practice for making clinical judgments and contains within it much judgment and experiential learning.

When clinical teaching is too removed from typical contingencies and strong clinical situations in practice, students will lack practice in active thinking-in-action in ambiguous clinical situations. In the following example, an anonymous student recounted her experiences of meeting a patient:

I was used to different equipment and didn’t know how things went, didn’t know their routine, really. You can explain all you want in class, this is how it’s going to be, but when you get there … . Kim was my first instructor and my patient that she assigned me to—I walked into the room and he had every tube imaginable. And so I was a little overwhelmed. It’s not necessarily even that he was that critical … . She asked what tubes here have you seen? Well, I know peripheral lines. You taught me PICC [peripherally inserted central catheter] lines, and we just had that, but I don’t really feel comfortable doing it by myself, without you watching to make sure that I’m flushing it right and how to assess it. He had a chest tube and I had seen chest tubes, but never really knew the depth of what you had to assess and how you make sure that it’s all kosher and whatever. So she went through the chest tube and explained, it’s just bubbling a little bit and that’s okay. The site, check the site. The site looked okay and that she’d say if it wasn’t okay, this is what it might look like … . He had a feeding tube. I had done feeding tubes but that was like a long time ago in my LPN experiences schooling. So I hadn’t really done too much with the feeding stuff either … . He had a [nasogastric] tube, and knew pretty much about that and I think at the time it was clamped. So there were no issues with the suction or whatever. He had a Foley catheter. He had a feeding tube, a chest tube. I can’t even remember but there were a lot.

As noted earlier, a central characteristic of a practice discipline is that a self-improving practice requires ongoing experiential learning. One way nurse educators can enhance clinical inquiry is by increasing pedagogies of experiential learning. Current pedagogies for experiential learning in nursing include extensive preclinical study, care planning, and shared postclinical debriefings where students share their experiential learning with their classmates. Experiential learning requires open learning climates where students can discuss and examine transitions in understanding, including their false starts, or their misconceptions in actual clinical situations. Nursing educators typically develop open and interactive clinical learning communities, so that students seem committed to helping their classmates learn from their experiences that may have been difficult or even unsafe. One anonymous nurse educator described how students extend their experiential learning to their classmates during a postclinical conference:

So for example, the patient had difficulty breathing and the student wanted to give the meds instead of addressing the difficulty of breathing. Well, while we were sharing information about their patients, what they did that day, I didn’t tell the student to say this, but she said, ‘I just want to tell you what I did today in clinical so you don’t do the same thing, and here’s what happened.’ Everybody’s listening very attentively and they were asking her some questions. But she shared that. She didn’t have to. I didn’t tell her, you must share that in postconference or anything like that, but she just went ahead and shared that, I guess, to reinforce what she had learned that day but also to benefit her fellow students in case that thing comes up with them.

The teacher’s response to this student’s honesty and generosity exemplifies her own approach to developing an open community of learning. Focusing only on performance and on “being correct” prevents learning from breakdown or error and can dampen students’ curiosity and courage to learn experientially.

Seeing the unexpected

One of the keys to becoming an expert practitioner lies in how the person holds past experiential learning and background habitual skills and practices. This is a skill of foregrounding attention accurately and effectively in response to the nature of situational demands. Bourdieu 29 calls the recognition of the situation central to practical reasoning. If nothing is routinized as a habitual response pattern, then practitioners will not function effectively in emergencies. Unexpected occurrences may be overlooked. However, if expectations are held rigidly, then subtle changes from the usual will be missed, and habitual, rote responses will inappropriately rule. The clinician must be flexible in shifting between what is in background and foreground. This is accomplished by staying curious and open. The clinical “certainty” associated with perceptual grasp is distinct from the kind of “certainty” achievable in scientific experiments and through measurements. Recognition of similar or paradigmatic clinical situations is similar to “face recognition” or recognition of “family resemblances.” This concept is subject to faulty memory, false associative memories, and mistaken identities; therefore, such perceptual grasp is the beginning of curiosity and inquiry and not the end. Assessment and validation are required. In rapidly moving clinical situations, perceptual grasp is the starting point for clarification, confirmation, and action. Having the clinician say out loud how he or she is understanding the situation gives an opportunity for confirmation and disconfirmation from other clinicians present. 111 The relationship between foreground and background of attention needs to be fluid, so that missed expectations allow the nurse to see the unexpected. For example, when the background rhythm of a cardiac monitor changes, the nurse notices, and what had been background tacit awareness becomes the foreground of attention. A hallmark of expertise is the ability to notice the unexpected. 20 Background expectations of usual patient trajectories form with experience. Tacit expectations for patient trajectories form that enable the nurse to notice subtle failed expectations and pay attention to early signs of unexpected changes in the patient's condition. Clinical expectations gained from caring for similar patient populations form a tacit clinical forethought that enable the experienced clinician to notice missed expectations. Alterations from implicit or explicit expectations set the stage for experiential learning, depending on the openness of the learner.

Learning to provide safe and quality health care requires technical expertise, the ability to think critically, experience, and clinical judgment. The high-performance expectation of nurses is dependent upon the nurses’ continual learning, professional accountability, independent and interdependent decisionmaking, and creative problem-solving abilities.

This section of the paper was condensed and paraphrased from Benner, Hooper-Kyriakidis, and Stannard. 23 Patricia Hooper-Kyriakidis wrote the section on clinical grasp, and Patricia Benner wrote the section on clinical forethought.

• Cite this Page Benner P, Hughes RG, Sutphen M. Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 6.
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Promoting critical thinking through an evidence-based skills fair intervention

Journal of Research in Innovative Teaching & Learning

ISSN : 2397-7604

Article publication date: 23 November 2020

Issue publication date: 1 April 2022

The lack of critical thinking in new graduates has been a concern to the nursing profession. The purpose of this study was to investigate the effects of an innovative, evidence-based skills fair intervention on nursing students' achievements and perceptions of critical thinking skills development.

Design/methodology/approach

The explanatory sequential mixed-methods design was employed for this study.

The findings indicated participants perceived the intervention as a strategy for developing critical thinking.

Originality/value

The study provides educators helpful information in planning their own teaching practice in educating students.

Critical thinking

Evidence-based practice, skills fair intervention.

Gonzalez, H.C. , Hsiao, E.-L. , Dees, D.C. , Noviello, S.R. and Gerber, B.L. (2022), "Promoting critical thinking through an evidence-based skills fair intervention", Journal of Research in Innovative Teaching & Learning , Vol. 15 No. 1, pp. 41-54. https://doi.org/10.1108/JRIT-08-2020-0041

Emerald Publishing Limited

Copyright © 2020, Heidi C. Gonzalez, E-Ling Hsiao, Dianne C. Dees, Sherri R. Noviello and Brian L. Gerber

Published in Journal of Research in Innovative Teaching & Learning . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Critical thinking (CT) was defined as “cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 357). Critical thinking is the basis for all professional decision-making ( Moore, 2007 ). The lack of critical thinking in student nurses and new graduates has been a concern to the nursing profession. It would negatively affect the quality of service and directly relate to the high error rates in novice nurses that influence patient safety ( Arli et al. , 2017 ; Saintsing et al. , 2011 ). It was reported that as many as 88% of novice nurses commit medication errors with 30% of these errors due to a lack of critical thinking ( Ebright et al. , 2004 ). Failure to rescue is another type of error common for novice nurses, reported as high as 37% ( Saintsing et al. , 2011 ). The failure to recognize trends or complications promptly or take action to stabilize the patient occurs when health-care providers do not recognize signs and symptoms of the early warnings of distress ( Garvey and CNE series, 2015 ). Internationally, this lack of preparedness and critical thinking attributes to the reported 35–60% attrition rate of new graduate nurses in their first two years of practice ( Goodare, 2015 ). The high attrition rate of new nurses has expensive professional and economic costs of $82,000 or more per nurse and negatively affects patient care ( Twibell et al. , 2012 ). Facione and Facione (2013) reported the failure to utilize critical thinking skills not only interferes with learning but also results in poor decision-making and unclear communication between health-care professionals, which ultimately leads to patient deaths.

Due to the importance of critical thinking, many nursing programs strive to infuse critical thinking into their curriculum to better prepare graduates for the realities of clinical practice that involves ever-changing, complex clinical situations and bridge the gap between education and practice in nursing ( Benner et al. , 2010 ; Kim et al. , 2019 ; Park et al. , 2016 ; Newton and Moore, 2013 ; Nibert, 2011 ). To help develop students' critical thinking skills, nurse educators must change the way they teach nursing, so they can prepare future nurses to be effective communicators, critical thinkers and creative problem solvers ( Rieger et al. , 2015 ). Nursing leaders also need to redefine teaching practice and educational guidelines that drive innovation in undergraduate nursing programs.

Evidence-based practice has been advocated to promote critical thinking and help reduce the research-practice gap ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). Evidence-based practice was defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient” ( Sackett et al. , 1996 , p. 71). Skills fair intervention, one type of evidence-based practice, can be used to engage students, promote active learning and develop critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention helps promote a consistent teaching practice of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The researchers of this study had an opportunity to create an active, innovative skills fair intervention for a baccalaureate nursing program in one southeastern state. This intervention incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students ( Hsu and Hsieh, 2013 ; Oermann et al. , 2011 ; Roberts et al. , 2009 ). The effects of an innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking development were examined in the study.

Literature review

The ability to use reasoned opinion focusing equally on processes and outcomes over emotions is called critical thinking ( Paul and Elder, 2008 ). Critical thinking skills are desired in almost every discipline and play a major role in decision-making and daily judgments. The roots of critical thinking date back to Socrates 2,500 years ago and can be traced to the ancient philosopher Aristotle ( Paul and Elder, 2012 ). Socrates challenged others by asking inquisitive questions in an attempt to challenge their knowledge. In the 1980s, critical thinking gained nationwide recognition as a behavioral science concept in the educational system ( Robert and Petersen, 2013 ). Many researchers in both education and nursing have attempted to define, measure and teach critical thinking for decades. However, a theoretical definition has yet to be accepted and established by the nursing profession ( Romeo, 2010 ). The terms critical literacy, CT, reflective thinking, systems thinking, clinical judgment and clinical reasoning are used synonymously in the reviewed literature ( Clarke and Whitney, 2009 ; Dykstra, 2008 ; Jones, 2010 ; Swing, 2014 ; Turner, 2005 ).

Watson and Glaser (1980) viewed critical thinking not only as cognitive skills but also as a combination of skills, knowledge and attitudes. Paul (1993) , the founder of the Foundation for Critical Thinking, offered several definitions of critical thinking and identified three essential components of critical thinking: elements of thought, intellectual standards and affective traits. Brunt (2005) stated critical thinking is a process of being practical and considered it to be “the process of purposeful thinking and reflective reasoning where practitioners examine ideas, assumptions, principles, conclusions, beliefs, and actions in the contexts of nursing practice” (p. 61). In an updated definition, Ennis (2011) described critical thinking as, “reasonable reflective thinking focused on deciding what to believe or do” (para. 1).

The most comprehensive attempt to define critical thinking was under the direction of Facione and sponsored by the American Philosophical Association ( Scheffer and Rubenfeld, 2000 ). Facione (1990) surveyed 53 experts from the arts and sciences using the Delphi method to define critical thinking as a “purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as an explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which judgment, is based” (p. 2).

To come to a consensus definition for critical thinking, Scheffer and Rubenfeld (2000) also conducted a Delphi study. Their study consisted of an international panel of nurses who completed five rounds of sequenced questions to arrive at a consensus definition. Critical thinking was defined as “habits of mind” and “cognitive skills.” The elements of habits of mind included “confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection” ( Scheffer and Rubenfeld, 2000 , p. 352). The elements of cognitive skills were recognized as “analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 352). In addition, Ignatavicius (2001) defined the development of critical thinking as a long-term process that must be practiced, nurtured and reinforced over time. Ignatavicius believed that a critical thinker required six cognitive skills: interpretation, analysis, evaluation, inference, explanation and self-regulation ( Chun-Chih et al. , 2015 ). According to Ignatavicius (2001) , the development of critical thinking is difficult to measure or describe because it is a formative rather than summative process.

Fero et al. (2009) noted that patient safety might be compromised if a nurse cannot provide clinically competent care due to a lack of critical thinking. The Institute of Medicine (2001) recommended five health care competencies: patient-centered care, interdisciplinary team care, evidence-based practice, informatics and quality improvement. Understanding the development and attainment of critical thinking is the key for gaining these future competencies ( Scheffer and Rubenfeld, 2000 ). The development of a strong scientific foundation for nursing practice depends on habits such as contextual perspective, inquisitiveness, creativity, analysis and reasoning skills. Therefore, the need to better understand how these critical thinking habits are developed in nursing students needs to be explored through additional research ( Fero et al. , 2009 ). Despite critical thinking being listed since the 1980s as an accreditation outcome criteria for baccalaureate programs by the National League for Nursing, very little improvement has been observed in practice ( McMullen and McMullen, 2009 ). James (2013) reported the number of patient harm incidents associated with hospital care is much higher than previously thought. James' study indicated that between 210,000 and 440,000 patients each year go to the hospital for care and end up suffering some preventable harm that contributes to their death. James' study of preventable errors is attributed to other sources besides nursing care, but having a nurse in place who can advocate and critically think for patients will make a positive impact on improving patient safety ( James, 2013 ; Robert and Peterson, 2013 ).

Adopting teaching practice to promote CT is a crucial component of nursing education. Research by Nadelson and Nadelson (2014) suggested evidence-based practice is best learned when integrated into multiple areas of the curriculum. Evidence-based practice developed its roots through evidence-based medicine, and the philosophical origins extend back to the mid-19th century ( Longton, 2014 ). Florence Nightingale, the pioneer of modern nursing, used evidence-based practice during the Crimean War when she recognized a connection between poor sanitary conditions and rising mortality rates of wounded soldiers ( Rahman and Applebaum, 2011 ). In professional nursing practice today, a commonly used definition of evidence-based practice is derived from Dr. David Sackett: the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient ( Sackett et al. , 1996 , p. 71). As professional nurses, it is imperative for patient safety to remain inquisitive and ask if the care provided is based on available evidence. One of the core beliefs of the American Nephrology Nurses' Association's (2019) 2019–2020 Strategic Plan is “Anna must support research to develop evidence-based practice, as well as to advance nursing science, and that as individual members, we must support, participate in, and apply evidence-based research that advances our own skills, as well as nursing science” (p. 1). Longton (2014) reported the lack of evidence-based practice in nursing resulted in negative outcomes for patients. In fact, when evidence-based practice was implemented, changes in policies and procedures occurred that resulted in decreased reports of patient harm and associated health-care costs. The Institute of Medicine (2011) recommendations included nurses being leaders in the transformation of the health-care system and achieving higher levels of education that will provide the ability to critically analyze data to improve the quality of care for patients. Student nurses must be taught to connect and integrate CT and evidence-based practice throughout their program of study and continue that practice throughout their careers.

One type of evidence-based practice that can be used to engage students, promote active learning and develop critical thinking is skills fair intervention ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention promoted a consistent teaching approach of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The skills fair intervention used in this study is a teaching strategy that incorporated CT prompts, Socratic questioning, group work, guided discussions, return demonstrations and blended learning in an attempt to develop CT in nursing students ( Hsu and Hsieh, 2013 ; Roberts et al. , 2009 ). It melded evidence-based practice with simulated CT opportunities while students practiced essential psychomotor skills.

Research methodology

Context – skills fair intervention.

According to Roberts et al. (2009) , psychomotor skills decline over time even among licensed experienced professionals within as little as two weeks and may need to be relearned within two months without performing a skill. When applying this concept to student nurses for whom each skill is new, it is no wonder their competency result is diminished after having a summer break from nursing school. This skills fair intervention is a one-day event to assist baccalaureate students who had taken the summer off from their studies in nursing and all faculty participated in operating the stations. It incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in baccalaureate students.

Students were scheduled and placed randomly into eight teams based on attributes of critical thinking as described by Wittmann-Price (2013) : Team A – Perseverance, Team B – Flexibility, Team C – Confidence, Team D – Creativity, Team E – Inquisitiveness, Team F – Reflection, Team G – Analyzing and Team H – Intuition. The students rotated every 20 minutes through eight stations: Medication Administration: Intramuscular and Subcutaneous Injections, Initiating Intravenous Therapy, ten-minute Focused Physical Assessment, Foley Catheter Insertion, Nasogastric Intubation, Skin Assessment/Braden Score and Restraints, Vital Signs and a Safety Station. When the students completed all eight stations, they went to the “Check-Out” booth to complete a simple evaluation to determine their perceptions of the effectiveness of the innovative intervention. When the evaluations were complete, each of the eight critical thinking attribute teams placed their index cards into a hat, and a student won a small prize. All Junior 2, Senior 1 and Senior 2 students were required to attend the Skills Fair. The Skills Fair Team strove to make the event as festive as possible, engaging nursing students with balloons, candy, tri-boards, signs and fun pre and postactivities. The Skills Fair rubrics, scheduling and instructions were shared electronically with students and faculty before the skills fair intervention to ensure adequate preparation and continuous resource availability as students move forward into their future clinical settings.

Research design

Institutional review board (IRB) approval was obtained from XXX University to conduct this study and protect human subject rights. The explanatory sequential mixed-methods design was employed for this study. The design was chosen to identify what effects a skills fair intervention that had on senior baccalaureate nursing students' achievements on the Kaplan Critical Thinking Integrated Test (KCTIT) and then follow up with individual interviews to explore those test results in more depth. In total, 52 senior nursing students completed the KCTIT; 30 of them participated in the skills fair intervention and 22 of them did not participate. The KCTIT is a computerized 85-item exam in which 85 equates to 100%, making each question worth one point. It has high reliability and validity ( Kaplan Nursing, 2012 ; Swing, 2014 ). The reliability value of the KCTIT ranged from 0.72 to 0.89. A t -test was used to analyze the test results.

A total of 11 participants were purposefully selected based on a range of six high achievers and five low achievers on the KCTIT for open-ended one-on-one interviews. Each interview was conducted individually and lasted for about 60 minutes. An open-ended interview protocol was used to guide the flow of data collection. The interviewees' ages ranged from 21 to 30 years, with an average of 24 years. One of 11 interviewees was male. Among them, seven were White, three were Black and one was Indian American. The data collected were used to answer the following research questions: (1) What was the difference in achievements on the KCTIT among senior baccalaureate nursing students who participated in the skills fair intervention and students who did not participate? (2) What were the senior baccalaureate nursing students' perceptions of internal and external factors impacting the development of critical thinking skills during the skills fair intervention? and (3) What were the senior baccalaureate nursing students' perceptions of the skills fair intervention as a critical thinking developmental strategy?

Inductive content analysis was used to analyze interview data by starting with the close reading of the transcripts and writing memos for initial coding, followed by an analysis of patterns and relationships among the data for focused coding. The intercoder reliability was established for qualitative data analysis with a nursing expert. The lead researcher and the expert read the transcript several times and assigned a code to significant units of text that corresponded with answering the research questions. The codes were compared based on differences and similarities and sorted into subcategories and categories. Then, headings and subheadings were used based on similar comments to develop central themes and patterns. The process of establishing intercoder reliability helped to increase dependability, conformability and credibility of the findings ( Graneheim and Lundman, 2004 ). In addition, methods of credibility, confirmability, dependability and transferability were applied to increase the trustworthiness of this study ( Graneheim and Lundman, 2004 ). First, reflexivity was observed by keeping journals and memos. This practice allowed the lead researcher to reflect on personal views to minimize bias. Data saturation was reached through following the recommended number of participants as well as repeated immersion in the data during analysis until no new data surfaced. Member checking was accomplished through returning the transcript and the interpretation to the participants to check the accuracy and truthfulness of the findings. Finally, proper documentation was conducted to allow accurate crossreferencing throughout the study.

Quantitative results

Results for the quantitative portion showed there was no difference in scores on the KCTIT between senior nursing students who participated in the skills fair intervention and senior nursing students who did not participate, t (50) = −0.174, p  = 0.86 > 0.05. The test scores between the nonparticipant group ( M  = 67.59, SD = 5.81) and the participant group ( M  = 67.88, SD = 5.99) were almost equal.

Qualitative results

Initial coding.

The results from the initial coding and generated themes are listed in Table 1 . First, the participants perceived the skills fair intervention as “promoting experience” and “confidence” by practicing previously learned knowledge and reinforcing it with active learning strategies. Second, the participants perceived the skills fair intervention as a relaxed, nonthreatening learning environment due to the festive atmosphere, especially in comparison to other learning experiences in the nursing program. The nonthreatening environment of the skills fair intervention allowed students to learn without fear. Third, the majority of participants believed their critical thinking was strengthened after participating. Several participants believed their perception of critical thinking was “enhanced” or “reinforced” rather than significantly changed.

Focused coding results

The final themes were derived from the analysis of patterns and relationships among the content of the data using inductive content analysis ( Saldana, 2009 ). The following was examined across the focused coding process: (1) factors impacting critical thinking skills development during skills fair intervention and (2) skills fair intervention a critical thinking skills developmental strategy.

Factors impacting critical thinking skills development . The factors impacting the development of critical thinking during the skills fair intervention were divided into two themes: internal factors and external factors. The internal factors were characteristics innate to the students. The identified internal factors were (1) confidence and anxiety levels, (2) attitude and (3) age. The external factors were the outside influences that affected the students. The external factors were (1) experience and practice, (2) faculty involvement, (3) positive learning environment and (4) faculty prompts.

I think that confidence and anxiety definitely both have a huge impact on your ability to be able to really critically think. If you start getting anxious and panicking you cannot think through the process like you need too. I do not really think gender or age necessarily would have anything to do with critical thinking.

Definitely the confidence level, I think, the more advanced you get in the program, your confidence just keeps on growing. Level of anxiety, definitely… I think the people who were in the Skills Fair for the first time, had more anxiety because they did not really know to think, they did not know how strict it was going to be, or if they really had to know everything by the book. I think the Skills Fair helped everyone's confidence levels, but especially the Jr. 2's.

Attitude was an important factor in the development of critical thinking skills during the skills fair intervention as participants believed possessing a pleasant and positive attitude meant a student was eager to learn, participate, accept responsibility for completing duties and think seriously. Participant 6 believed attitude contributed to performance in the Skills Fair.

I feel like, certain things bring critical thinking out in you. And since I'm a little bit older than some of the other students, I have had more life experiences and am able to figure stuff out better. Older students have had more time to learn by trial and error, and this and that.

Like when I had clinical with you, you'd always tell us to know our patients' medications. To always know and be prepared to answer questions – because at first as a Junior 1 we did not do that in the clinical setting… and as a Junior 2, I did not really have to know my medications, but with you as a Senior 1, I started to realize that the patients do ask about their meds, so I was making sure that I knew everything before they asked it. And just having more practice with IVs – at first, I was really nervous, but when I got to my preceptorship – I had done so many IVs and with all of the practice, it just built up my confidence with that skill so when I performed that skill during the Fair, I was confident due to my clinical experiences and able to think and perform better.

I think teachers will always affect the ability to critically think just because you want [to] get the right answer because they are there and you want to seem smart to them [Laugh]. Also, if you are leading in the wrong direction of your thinking – they help steer you back to [in] the right direction so I think that was very helpful.

You could tell the faculty really tried to make it more laid back and fun, so everybody would have a good experience. The faculty had a good attitude. I think making it fun and active helped keep people positive. You know if people are negative and not motivated, nothing gets accomplished. The faculty did an amazing job at making the Skills Fair a positive atmosphere.

However, for some of the participants, a positive learning environment depended on their fellow students. The students were randomly assigned alphabetically to groups, and the groups were assigned to starting stations at the Skills Fair. The participants claimed some students did not want to participate and displayed cynicism toward the intervention. The participants believed their cynicism affected the positive learning environment making critical thinking more difficult during the Skills Fair.

Okay, when [instructor name] was demonstrating the Chevron technique right after we inserted the IV catheter and we were trying to secure the catheter, put on the extension set, and flush the line at what seemed to be all at the same time. I forgot about how you do not want to put the tape right over the hub of the catheter because when you go back in and try to assess the IV site – you're trying to assess whether or not it is patent or infiltrated – you have to visualize the insertion site. That was one of the things that I had been doing wrong because I was just so excited that I got the IV in the vein in the first place – that I did not think much about the tape or the tegaderm for sterility. So I think an important part of critical thinking is to be able to recognize when you've made a mistake and stop, stop yourself from doing it in the future (see Table 2 ).

Skills fair intervention as a developmental strategy for critical thinking . The participants identified the skills fair intervention was effective as a developmental strategy for critical thinking, as revealed in two themes: (1) develops alternative thinking and (2) thinking before doing (See Table 3 ).

Develops alternative thinking . The participants perceived the skills fair intervention helped enhance critical thinking and confidence by developing alternative thinking. Alternative thinking was described as quickly thinking of alternative solutions to problems based on the latest evidence and using that information to determine what actions were warranted to prevent complications and prevent injury. It helped make better connections through the learning of rationale between knowledge and skills and then applying that knowledge to prevent complications and errors to ensure the safety of patients. The participants stated the learning of rationale for certain procedures provided during the skills fair intervention such as the evidence and critical thinking prompts included in the rubrics helped reinforce this connection. The participants also shared they developed alternative thinking after participating in the skills fair intervention by noticing trends in data to prevent potential complications from the faculty prompts. Participant 1 stated her instructor prompted her alternative thinking through questioning about noticing trends to prevent potential complications. She said the following:

Another way critical thinking occurred during the skills fair was when [instructor name] was teaching and prompted us about what it would be like to care for a patient with a fractured hip – I think this was at the 10-minute focused assessment station, but I could be wrong. I remember her asking, “What do you need to be on the look-out for? What can go wrong?” I automatically did not think critically very well and was only thinking circulation in the leg, dah, dah, dah. But she was prompting us to think about mobility alterations and its effect on perfusion and oxygenation. She was trying to help us build those connections. And I think that's a lot of the aspects of critical thinking that gets overlooked with the nursing student – trouble making connections between our knowledge and applying it in practice.

Thinking before doing . The participants perceived thinking before doing, included thinking of how and why certain procedures, was necessary through self-examination prior to taking action. The hands-on situational learning allowed the participants in the skills fair intervention to better notice assessment data and think at a higher level as their previous learning of the skills was perceived as memorization of steps. This higher level of learning allowed participants to consider different future outcomes and analyze pertinent data before taking action.

I think what helped me the most is considering outcomes of my actions before I do anything. For instance, if you're thinking, “Okay. Well, I need to check their blood pressure before I administer this blood pressure medication – or the blood pressure could potentially bottom out.” I really do not want my patient to bottom out and get hypotensive because I administered a medication that was ordered, but not safe to give. I could prevent problems from happening if I know what to be on alert for and act accordingly. So ultimately knowing that in the clinical setting, I can prevent complications from happening and I save myself, my license, and promote patient safety. I think knowing that I've seen the importance of critical thinking already in practice has helped me value and understand why I should be critically thinking. Yes, we use the 5-rights of medication safety – but we also have to think. For instance, if I am going to administer insulin – what do I need to know or do to give this safely? What is the current blood sugar? Has the patient been eating? When is the next meal scheduled? Is the patient NPO for a procedure? Those are examples of questions to consider and the level of thinking that needs to take place prior to taking actions in the clinical setting.

Although the results of quantitative data showed no significant difference in scores on the KCTIT between the participant and nonparticipant groups, during the interviews some participants attributed this result to the test not being part of a course grade and believed students “did not try very hard to score well.” However, the participants who attended interviews did identify the skills fair intervention as a developmental strategy for critical thinking by helping them develop alternative thinking and thinking before doing. The findings are supported in the literature as (1) nurses must recognize signs of clinical deterioration and take action promptly to prevent potential complications ( Garvey and CNE series 2015 ) and (2) nurses must analyze pertinent data and consider all possible solutions before deciding on the most appropriate action for each patient ( Papathanasiou et al. , 2014 ).

The skills fair intervention also enhanced the development of self-confidence by participants practicing previously learned skills in a controlled, safe environment. The nonthreatening environment of the skills fair intervention allowed students to learn without fear and the majority of participants believed their critical thinking was strengthened after participating. The interview data also revealed a combination of internal and external factors that influenced the development of critical thinking during the skills fair intervention including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

Conclusions, limitations and recommendations

A major concern in the nursing profession is the lack of critical thinking in student nurses and new graduates, which influences the decision-making of novice nurses and directly affects patient care and safety ( Saintsing et al. , 2011 ). Nurse educators must use evidence-based practice to prepare students to critically think with the complicated and constantly evolving environment of health care today ( Goodare, 2015 ; Newton and Moore, 2013 ). Evidence-based practice has been advocated to promote critical thinking ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). The skills fair intervention can be one type of evidence-based practice used to promote critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). The Intervention used in this study incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students.

The explanatory sequential mixed-methods design was employed to investigate the effects of the innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking skills development. Although the quantitative results showed no significant difference in scores on the KCTIT between students who participated in the skills fair intervention and those who did not, those who attended the interviews perceived their critical thinking was reinforced after the skills fair intervention and believed it was an effective developmental strategy for critical thinking, as it developed alternative thinking and thinking before doing. This information is useful for nurse educators who plan their own teaching practice to promote critical thinking and improve patient outcomes. The findings also provide schools and educators information that helps review their current approach in educating nursing students. As evidenced in the findings, the importance of developing critical thinking skills is crucial for becoming a safe, professional nurse. Internal and external factors impacting the development of critical thinking during the skills fair intervention were identified including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

There were several limitations to this study. One of the major limitations of the study was the limited exposure of students' time of access to the skills fair intervention, as it was a one-day learning intervention. Another limitation was the sample selection and size. The skills fair intervention was limited to only one baccalaureate nursing program in one southeastern state. As such, the findings of the study cannot be generalized as it may not be representative of baccalaureate nursing programs in general. In addition, this study did not consider students' critical thinking achievements prior to the skills fair intervention. Therefore, no baseline measurement of critical thinking was available for a before and after comparison. Other factors in the nursing program could have affected the students' scores on the KCTIT, such as anxiety or motivation that was not taken into account in this study.

The recommendations for future research are to expand the topic by including other regions, larger samples and other baccalaureate nursing programs. In addition, future research should consider other participant perceptions, such as nurse educators, to better understand the development and growth of critical thinking skills among nursing students. Finally, based on participant perceptions, future research should include a more rigorous skills fair intervention to develop critical thinking and explore the link between confidence and critical thinking in nursing students.

Initial coding results

Factors impacting critical thinking skill development during skills fair intervention

Skills fair intervention as a developmental strategy for critical thinking

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Critical Thinking Skills.

Ai generator.

Critical thinking is the ability to analyze information objectively and make a reasoned judgment. It involves evaluating sources, such as data, facts, observable phenomena, and research findings. Developing critical thinking skills is essential for academic success and everyday decision-making. Here are strategies and examples to help enhance critical thinking skills.

1. Ask Questions

Asking questions is fundamental to critical thinking. Encourage curiosity and in-depth understanding by asking questions like:

• What evidence supports this claim?
• Are there alternative perspectives?
• What are the implications of this decision?

2. Analyze Assumptions

Identifying and analyzing assumptions helps in understanding underlying biases and beliefs.

• Example : When reading a news article, identify the assumptions the author makes and consider how they influence the argument.

3. Evaluate Evidence

Evaluating evidence involves assessing the reliability and validity of information sources.

• Example : When researching a topic, compare information from multiple sources and evaluate their credibility.

4. Develop Hypotheses

Formulating and testing hypotheses can strengthen analytical skills.

• Example : In a science experiment, develop a hypothesis, conduct experiments to test it, and analyze the results.

5. Reflect on Your Thinking Process

Reflection helps in recognizing and improving your thought process.

• Example : After making a decision, reflect on the steps you took, what you learned, and how you could improve in the future.

6. Engage in Discussions

Participating in discussions encourages the exchange of ideas and perspectives.

• Example : Join a debate club or discussion group to practice presenting and defending your viewpoints.

7. Practice Problem-Solving

Solving problems systematically can enhance critical thinking.

• Example : Use problem-solving frameworks, like SWOT analysis, to evaluate a business case study.

8. Use Critical Thinking Exercises

Incorporate exercises and activities designed to boost critical thinking skills.

• Example : Engage in brainteasers, puzzles, and logic games that challenge your reasoning abilities.

Examples of Critical Thinking in Action

• Case Study: Socratic Method : Used in law schools, the Socratic method involves asking a series of questions to help students think deeply about the subject matter.
• Example: Reflective Journals : Students keep journals where they reflect on their learning experiences, analyze their thinking processes, and develop insights.

Developing critical thinking skills is crucial for academic success and informed decision-making. By asking questions, analyzing assumptions, evaluating evidence, developing hypotheses, reflecting on thinking processes, engaging in discussions, practicing problem-solving, and using critical thinking exercises, individuals can enhance their ability to think critically.

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Global history is not just significant events on a timeline, it is also the ordinary, mundane moments that people experience in between. Graphic novels can capture this multidimensionality in ways that are difficult, and sometimes impossible, in more traditional media formats, says Stanford history professor Tom Mullaney .

Tom Mullaney, a professor of history in the School of Humanities and Sciences, uses graphic novels in his teachings to help students appreciate different experiences and perspectives throughout history. (Image credit: Ilmiyah Achmad)

Mullaney has incorporated graphic novels in some of his Stanford courses since 2017; in 2020, he taught a course dedicated to the study of world history through comic strip formats.

While graphic novels are not a substitute for academic literature, he said he finds them a useful teaching and research tool. They not only portray the impact of historic events on everyday lives, but because they can be read in one or two sittings, they get to it at a much faster rate than say a 10,000 word essay or autobiography could.

“It accelerates the process of getting to subtlety,” said Mullaney, a professor of history at Stanford’s School of Humanities and Sciences . “There’s just so much you can do, and so many questions you can ask, and so many perspective shifts you can carry out – like that! You can just do it – you show them something, they read it and BOOM! It’s like an accelerant. It’s awesome.”

For example, in Thi Bui’s graphic novel The Best We Could Do , themes of displacement and diaspora emerge as she talks about her family’s escape from war-torn Vietnam to the United States. The illustrated memoir shows Bui’s upbringing in suburban California and the complicated memories her parents carry with them as they move about their new life in America. In other chapters, she depicts her mother and father back in Vietnam and what their own childhood was like amidst the country’s upheaval.

Graphic novels like The Best We Could Do and also Maus , Art Spiegelman’s seminal portrayal of his Jewish family’s experience during the Holocaust, illustrate the challenges and subtleties of memory – particularly family memory – and the entanglements that arise when narrating history, Mullaney said.

Graphic novels prime readers for the complexity of doing and reading historical research and how there is no simplistic, narrative arc of history. “When I read a graphic novel, I feel prepared to ask questions that allow me to go into the harder core, peer-reviewed material,” Mullaney said.

The everyday moments that graphic novels are exceptionally good at capturing also raise questions in the reader’s mind, Mullaney said. Readers sit in the family living room and at the kitchen table with Spiegelman and Bui and follow along as their characters try to understand what their parent’s generation went through and discover it’s not always easy to grasp. “Not everything mom and dad say makes sense,” said Mullaney.

These seemingly mundane moments also present powerful opportunities for inquiry. “The ordinary  is where the explanation lives and where you can start asking questions,” Mullaney added.

Graphic novels can also depict how in periods of war and conflict, violence can become part of everyday existence and survival. The simplicity of the format allows heavy, painful experiences to emerge from a panel untethered and unweighted from lengthy descriptions or dramatizations.

“They’re banal. They’re not dramatic. There are no strings attached. In a work of nonfiction, in an article or book, it would be almost impossible to do that. There would have to be so much expository writing and so much description that you would lose the horror of it,” Mullaney said.

A ‘fundamental misunderstanding’

Graphic novels like Maus and The Best We Could Do were included in Mullaney’s 2020 Stanford class, Global History Through Graphic Novels .

In 2020, Tom Mullaney, a professor of history, taught Global History Through Graphic Novels , a course that paired graphic novels such as Art Spiegelman’s Maus with archival materials and historical essays to examine modern world history from the 18th to the 21st century. He created a poster for the class, as shown here. (Image credit: Tom Mullaney)

In the course, Mullaney paired graphic novels with archival materials and historical essays to examine modern world history from the 18th to the 21st century.

The course syllabus also included the graphic novels Showa , Shigeru Mizuki ’s manga series about growing up in Japan before World War II, and Such a Lovely Little War , about Marcelino Truong’s experience as a child in Saigon during the Vietnam War.

Most recently, Mullaney has offered to teach a variation of the Stanford course to the public, free for high school and college students , this summer.

Registration for the online course opened shortly after news emerged and made international headlines that Maus was banned by a Tennessee school board for its depiction of nudity and use of swear words.

Within two days of Mullaney’s course registration opening, over 200 students from across the world signed up.

Mullaney believes that there is a “fundamental misunderstanding” about what young people can process when it comes to negotiating complex themes and topics – whether it is structural racism or the Holocaust. They just need some guidance, which he hopes as a teacher, he can provide.

“I think students of high school age or even younger, if they have the scaffolding they need – which is the job of educators to give them – they can handle the structural inequalities, darknesses and horrors of life,” he said.

Mullaney noted that many teenagers are already exposed to many of these difficult issues through popular media. “But they’re just doing it on their own and figuring it out for themselves – that’s not a good idea,” he said.

Mullaney said he hopes he can teach Global History Through Graphic Novels to Stanford students again this fall.

For Stanford scholars interested in learning more about the intersection of graphic novels and scholarship, there is a newly established working group through the Division of Literatures, Cultures and Languages, Comics, More than Words .

Media Contacts

Melissa De Witte, Stanford News Service:  [email protected]

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So, you want to grow hair.

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If you want to make a lot of money, all you have to do is come up with an effective treatment for androgenic alopecia. That’s male pattern baldness. Actually, even a minimally effective product will do. Or one that has no efficacy at all, like a shampoo that claims to “unclog the scalp by cleaning follicles,” or a brush that “stimulates hair growth.” That’s because hair loss is so distressing, and so damaging to self-esteem, that many men are willing to plunk down money for anything that hints at regrowth, be it a drug, some “natural” concoction, or a cap that delivers “low level laser light therapy" (LLLT).

There is no single cause for hair loss. Genetics, nutritional deficiencies, hormonal changes, certain medical conditions and stress all play possible roles. The best studied influencer has been dihydrotestosterone (DHT), a hormone that causes hair follicles, the shafts in the skin from which hair grows, to shrink. This results in thinner hairs and eventually no hairs being produced. Since dihydrotestosterone forms from testosterone through the activity of the enzyme alpha-reductase, inhibiting this enzyme can prevent hair loss. Finasteride (Propecia) is an oral medication that interferes with the activity of this enzyme and leads to modest regrowth. It certainly cannot be used by women of child bearing age because finasteride can cause fetal abnormalities and it hasn’t been studied in post-menopausal women.

The cells that make up the hair follicle need the appropriate raw materials, namely amino acids, vitamins and minerals, to produce keratin, the protein that is the basic component of hair. These are delivered through the bloodstream so that any increased circulation through the scalp benefits hair growth. Minoxidil (Rogaine) is a topical medication that widens blood vessels and increases nutrient and oxygen delivery. This causes follicles that are in the telogen phase, the resting phase of the hair growth cycle, to revert to anagen, the active growing phase. Minoxidil can be used by men or women and is most effective at the first sign of hair loss. In rare cases, hair loss is due to a nutrient deficient diet, particularly one that lacks biotin, a B vitamin. In this case a biotin supplement can help.

A number of “natural” oral supplements have also appeared on the market with Nutrafol, Viviscal and Replenology being widely promoted. Each one of these contains a plethora of ingredients that are said to have been selected based on scientific evidence for supporting hair growth. Since these supplements are regulated as “natural health products,” there is no requirement to provide any evidence of efficacy.

Reprenology, for example, is a system that combines an oral supplement, a shampoo, a conditioner and a “follicle serum.” The capsule alone contains 28 ingredients! What are they? Vitamins, minerals and a host of plant extracts in unknown amounts. I don’t know what  Malus domestica , which is the common apple, has to do with hair growth, but  Moringa oleifera , the “drumstick tree,” has some anti-alpha reductase activity.  Eclipta prostrata , also known as “false daisy,” can supposedly stimulate anagen. These ingredients are also present in the “follicle serum,” although instead of  Malus domestica , we have  Pyrus malus , which is crabapple. I’m not just being crabby when I say there is no evidence for this, but there isn’t any. Caffeine is also included for some unknown reason.

Curiously, Reprenology contains no saw palmetto which is known to be an alpha reductase inhibitor. However, it is present in Nutrafol, which has a different grab bag of ingredients that include curcumin, ashwagandha and hydrolyzed marine collagen along with an array of vitamins and minerals. Then there is Viviscal, which for some reason specifically targets women with its “proprietary blend of shark and mullusk powder, organic silica, microcrystalline cellulose, magnesium citrate, hypromellose and glycerol.

Putting aside the questionable science behind assembling the cacophony of ingredients found in these natural products, the question we are interested in is whether the products can actually grow hair. Well, they can. Just not very much of it in most cases. There actually are some double-blind clinical trials that definitely document growth, but the problem is that the documentation is generally expressed in terms of hairs per square centimeter. It is difficult to know how that translates to a practical effect. An increase of 20 hairs per square centimeter may be statistically significant, but does it mean that an observer will take notice? Without proper statistics of user satisfaction backed up by photos, we just don’t know. Results with all these hair growth products seem to be very variable, so the only way to find out if one works is to open your wallet and give it a try. And get ready to open that wallet quite wide. Although not as wide as for a cap that targets the scalp with red light emitted at a wavelength of 655 nanometers that supposedly increases circulation in the scalp. Here we are talking over a thousand dollars for a hat that has to be worn for about half an hour a day for months. Again, there is evidence for some growth, but to variable extents. However, if you really want to be noticed as sporting new hair, transplants have improved significantly. And of course, there are wigs. They unquestionably work.

@JoeSchwarcz

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